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Pharmaceutical Benefits

under State Medical Assistance


Programs

2000

Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433

©2000 by the National Pharmaceutical Council


This compilation of data on State Medical Assistance Programs (Title XIX)
presents a general overview of the characteristics of state programs, together
with detailed information on the pharmaceutical benefits provided. The data
collection effort covers all states with Medicaid programs and the District of
Columbia.

Information for this compilation was acquired from multiple sources, including a
survey of Medicaid prescription drug programs, administered for the National
Pharmaceutical Council by The Lewin Group, Falls Church, Virginia. While we
have checked all secondary data in the book for consistency relative to the
original source, we have not validated the original data reported by the Health
Care Financing Administration (HCFA) and other organizations.

The data were compiled and the book prepared for publication by Catherine
Harrington, Dawn Bartoszewicz, Corinna Sorenson, Haejin Chung and Sheela
Raju of The Lewin Group; and Kimberly Dietrich of the National
Pharmaceutical Council.
Pharmaceutical Benefits 2000

INTRODUCTION

The year 2000 edition of Pharmaceutical Benefits under State Medical


Assistance Programs marks the 35th year that the National Pharmaceutical
Council (NPC) has published this unique source of information on pharmacy
programs within the State Medical Assistance Programs (Title XIX). Over the
years, this “Medicaid Compilation” of statistics has become a standard reference
in government offices, research libraries, consultancies, and numerous
corporations.

The “Medicaid Compilation” incorporates information on each State pharmacy


program from an annual NPC survey of State Medicaid program administrators
and pharmacy consultants and statistics from the Health Care Financing
Administration (HCFA). A main data source of the compilation, the HCFA-
2082, is an annual report providing State-reported data on Medicaid population
characteristics and utilization during a Federal fiscal year.

Historically, states summarized and reported data processed through their


Medicaid claims processing and payment operations unless they opted to
participate in the Medicaid Statistical Information System (MSIS) project. Prior
to Federal fiscal year 1999, MSIS was a voluntary program where states
participating in the MSIS project provided data tapes from their claims
processing systems to HCFA in lieu of the 2082 tables. In accordance with the
Balanced Budget Act of 1997, all claims processed on or after January 1, 1999,
had to be submitted electronically in the MSIS format. This new requirement
has caused some states to have difficulty providing data to HCFA within the
normal timeframe, which has resulted in a delay in the release of the HCFA-
2082 report for fiscal year 1999.

Because of this delay, the NPC is presenting this preliminary draft of the
“Medicaid Compilation, 2000” in Adobe Portable Document Format (PDF).
This preliminary draft contains the latest information provided by State
Medicaid program administrators and pharmacy consultants for Federal fiscal
year 1999, however, it still contains Medicaid population characteristics and
utilization based on the 1998 HCFA-2082 report. Once the HCFA-2082 report
for fiscal year 1999 is released by HCFA, the NPC and The Lewin Group will
update the information and make the full printed edition of the book available.

In order to give a better understanding of the content of the “Medicaid


Compilation,” the information contained in this version of the book is
summarized below by section:

• Section 1: Reports on the trends in of Medicaid expenditures over the last


decade (through 1999, the last year data are available) and highlights
differences between Medicaid and national spending.

• Section 2: Contains details about Medicaid Managed Care enrollment as of


June 30, 1999, including a breakdown by plan type and enrollment by plan
type.

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• Section 3: Consists of sociodemographic statistics, by age, race, insurance,


income, and employment, for the fifty states and the District of Columbia for
the calendar year 1999. Additionally, a description of the Medicaid certified
facilities in each state, including the number of hospitals, skilled nursing
facilities, and ICF-MR facilities, home health agencies, and rural health
clinics are presented.

• Section 4: Provides Medicaid pharmacy program characteristics, drawn


largely from the 2000 NPC annual survey of State pharmacy program
administrators. In addition, this section provides Medicaid statistics from
the Health Care Financing Administration for fiscal year 1998 (the last year
data are available). Medicaid pharmacy programs are characterized by
estimates of total payments and recipients, drug payments and recipients,
drug benefit design, and pharmacy payment and patient cost sharing.

• Section 5: Profiles the 20 states that are providing pharmaceutical coverage


for the elderly, as of December 31, 2000.

• Section 6: Contains detailed profiles of the States’ Medicaid pharmacy


programs. This section contains a description of medical assistance benefits
and eligibles, drug payments and recipients, benefit design, pharmacy
payment and patient cost sharing, use of managed care, and state contacts.

The book also contains a series of appendixes. Appendix A features a list of


State contacts, HCFA regional offices and Medicaid bureau personnel.
Appendix B provides HCFA statistics on Medicaid eligibles, recipients, and
payments (FY 1998 HCFA-2082 data). Appendix C provides the current
Medicaid drug rebate law. Appendix D contains the list of HCFA upper limits
on multiple source products. Appendix E is a glossary and list of acronyms and
Appendix F lists an index for keywords.

NPC gratefully acknowledges the cooperation and assistance of the many state
and federal program officials and their staffs, and The Lewin Group for
administering the survey and analyzing the data.

We hope you continue to find the information contained in this compilation


useful and, as always, we welcome your suggestions and comments.

Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council

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TABLE OF CONTENTS

INTRODUCTION....................................................................................................................................iii

SECTION 1: EXPENDITURE TRENDS IN MEDICAID.................................................................1-1

SECTION 2: MEDICAID MANAGED CARE ...................................................................................2-1

Medicaid Managed Care Enrollment.......................................................................................2-3

Medicaid Managed Care Waivers ..........................................................................................2-11

SECTION 3: STATE CHARACTERISTICS .....................................................................................3-1

Sociodemographics
− Age Demographics .....................................................................................................3-3
− Race Demographics....................................................................................................3-4
− Insurance Status..........................................................................................................3-5
− Income and Employment............................................................................................3-6
Health Care Delivery System
− Medicaid/Medicare Certified Facilities......................................................................3-7
− Licensed Pharmacies ..................................................................................................3-8
− Physicians.................................................................................................................3-10
− Other Providers ........................................................................................................3-11

SECTION 4: PHARMACY PROGRAM CHARACTERISTICS.....................................................4-1

The Medicaid Program..............................................................................................................4-3


− Total U.S. Medical Assistance Recipients ...............................................................4-10
− Total U.S. Medical Assistance Payments.................................................................4-11
− Federal Medical Assistance Percentages..................................................................4-12
− Medicaid Payments and Recipients..........................................................................4-13

Medicaid Drug Program..........................................................................................................4-15


− Drug Payments and Recipients.................................................................................4-27
− Drug Payment Trends...............................................................................................4-28
− Drug Payment – Percent Change from 1997 to 1998...............................................4-19
− Ranking Based on Drug Payments ...........................................................................4-20
− Drugs as a Percentage of Total Vendor Payments ...................................................4-21
− Drugs as a Percentage of Total Vendor Payments, Trends ......................................4-22
− Share of Drug Payments, Top 5 Therapeutic Categories .........................................4-23
− Total Drug Recipients ..............................................................................................4-24
− Drug Payments Per Recipient...................................................................................4-25

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− Medicaid Drug Reimbursement Report ...................................................................4-26

Medicaid Drug Rebates ...........................................................................................................4-27


− Medicaid Drug Rebates ............................................................................................4-28
− Medicaid Drug Rebate Trends .................................................................................4-29

Medicaid Drug Coverage.........................................................................................................4-31


− Pharmacy Advisory Committees..............................................................................4-33
− Pharmacy Benefit Design – Coverage......................................................................4-34
− Coverage of Injectables ............................................................................................4-37
− Coverage of Vaccines and Unit Dose.......................................................................4-38
− Coverage of Over-the-Counter Medications ............................................................4-39
− Prior Authorization Process and Procedures ............................................................4-41
− Prior Authorization...................................................................................................4-44
− Drug Utilization Review ..........................................................................................4-47
− Prescribing and Dispensing Limits...........................................................................4-48

Pharmacy Payment and Patient Cost Sharing ......................................................................4-49


− Pharmacy Payment and Patient Cost Sharing ..........................................................4-51
− Maximum Allowable Cost Programs.......................................................................4-52
− Mandatory Substitution ............................................................................................4-53
− Counseling Requirements and Payment for Cognitive Services..............................4-54
− Prescription Price Updating .....................................................................................4-55

SECTION 5: EXPANDED DRUG COVERAGE FOR THE ELDERLY ........................................5-1

SECTION 6: STATE PROFILES ........................................................................................................6-1

APPENDIXES
Appendix A: State and Federal Medicaid Contacts .................................................................... A-1
Appendix B: Medicaid Program Statistics – HCFA-2082 Report .............................................. B-1
Appendix C: Medicaid Rebate Law ............................................................................................ C-1
Appendix D: HCFA Upper Limits for Multiple Source Products............................................... D-1
Appendix E: Glossary ................................................................................................................. E-1

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Section 1:
Expenditure Trends
in Medicaid

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EXPENDITURE TRENDS IN MEDICAID

Medicaid programs account for a significant portion of all health care expenditures in the United States.
In 1999, Medicaid expenditures totaled $187.0 billion, which is 15.4% of national health care
expenditures.1 Managing a Medicaid budget requires an understanding of the forces that influence
trends in spending including changes in policy at both the state and federal levels. Changes in policy
impact important factors that drive total expense including population size and demographic mix, prices,
managed care penetration, and supply of services (i.e., number of providers). This section focuses on
understanding the trends in of Medicaid expenditures over the last decade (through 1999, the last year
data are available) and highlighting differences between Medicaid and national spending.

SPENDING TRENDS

Overall, Medicaid expenditures have more than doubled in the last decade, from $93.2 million in 1991
to $187.0 million in 1999; however, the spending growth rate has been affected by program changes
over the last decade.1 As seen in Figure 1-1, the rate of growth dropped throughout most of the decade
but then started to rise in 1997. During the early to mid 90’s, welfare reform, moderate growth of the
aged and disabled population, and an improved economy lead to a reduction in spending growth; indeed,
all these led to changes in population size and mix effects.2 Also, increased use of managed care
affected utilization incentives and the supply of providers. More recently, in the late 90’s, eligibility
expansion due to the passage of State Children’s Health Insurance Plans (also known as Title XXI as
part of the Balanced Budget Act of 1997) has lead to an increase in the spending growth rate.1

Figure 1-1: Medicaid Expenditures and Growth Rates1

$250

26.6% 25
$187.0
$200 $171.7
$159.8 20
$152.2
$144.1
$150 16.0% $133.7
$121.6
$108.2 15
$93.2
$100
12.4% 10
10.0%
8.9%
$50 7.7% 7.5% 5
5.6% 5.0%
$0 0
1991 1992 1993 1994 1995 1996 1997 1998 1999

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Figure 1-2 shows that the majority of payments in Medicaid is for long-term care services which include
skilled nursing, mental retardation, home health care, and mental health institutions. The spending rate
increase in long-term care is primarily due to rising expenditures for home health services. In 1998,
home health expenses were split into three categories, traditional home health, home and community-
based care, and personal care. Together, spending in the home care categories increased spending 44%
over home health care spending in 1997. Spending for skilled nursing facility services in Medicaid has
been fairly flat with a 4.6% increase from 1997 to 1998). Spending for prescription drugs is also rising
(12.5% increase, 1997-1998), however, the total share of dollars is still relatively small. Spending for
hospital inpatient services and physician services has decreased.3

Figure 1-2: Distribution of Medicaid Spending* by Type of Service3

$70
62^
1995
$60 55
51 52 1996
$50 1997
1998
$40

$30 26 25
23 22 21 21 20
18
$20 14
10 11 12
$10

$0
LTC± Hospital - Physician† Prescription Drugs
Inpatient‡

* Excludes managed care payments


± LTC (long-term care) = nursing facilities, mental health, home health, and mental retardation facilities
‡ Direct payments for services
† Physician, lab, clinic, EPSDT, outpatient hospital
^ Due to a category change, the 1998 LTC figure also includes payments for home and community based services and
personal care support services

POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE

Medicaid is the largest financier of health care in the United States in terms of number of beneficiaries.
In 1998, there were 40.6 million Medicaid beneficiaries.4 This number represents an increase of about
12 million Medicaid recipients since 1991, although recent changes to welfare laws and an improved
economy resulted in a decline in the number of eligible people (from 41.6 million in 1997 to 41.4 in
1998).4 In the past, it was automatically assumed that a person who was on welfare would qualify for
the Medicaid program. Recently, welfare reform has resulted in a break in the link between public
assistance and Medicaid. This change was originally intended to allow people who did not receive

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public assistance to still qualify for medical coverage. However, due to complex eligibility
requirements, applying for Medicaid is a confusing and difficult process for many people, resulting in
fewer enrollees. Besides the working poor and those on assistance, Medicaid coverage can be extended
to low income people who are elderly, blind, or disabled. In 1998, the majority of Medicaid funds, 71%
of expenditures, were spent on aged, blind, and disabled beneficiaries (who constitute only 26% of
persons served).5 In contrast, in 1998, children made up 53% of the total beneficiaries, yet only 14% of
all Medicaid expenditures went toward children.5 Figure 1-3 below examines the breakdown of
Medicaid expenditures by eligibility type.

Figure 1-3: Medicaid Expenditures & Enrollment by Group, 19985

$101.0
$100

$80

$60

$40

$20.5 18.3 M
$20 $14.8
7.9 M 10.6 M

$0
Adults Children Aged, Blind, & Disabled

Notes: Figures do not include spending for administration ($6.4 B) or disproportionate share hospitals ($15.9 B). Enrollment
figures are in millions.

MANAGED CARE TRENDS

The percentage of beneficiaries enrolled in Medicaid managed care increased from 9.5% in 1991 to
55.6% in 1999.6 The majority of those enrolled in managed care are non-disabled adults and children
where enrollment is mandatory. Over half of all Medicaid managed care enrollees are in a Health
Maintenance Organization (HMO) or Health Insuring Organization (HIO), organizations that contract on
a prepaid capitated risk basis to provide a comprehensive set of services. Room for further growth in
Medicaid managed care exists in the medically needy population of older and disabled persons.
However, the outlook for Medicaid managed care is cloudy right now because of the withdrawal of
many managed care firms from both the Medicare and Medicaid markets.7

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PROVIDER PARTICIPATION IN MEDICAID

Physician participation in the fee-for-service Medicaid program is low. In many geographic areas patient
access to primary care services is limited. Physicians hesitate to take on Medicaid patients because
Medicaid reimburses at a much lower rate than does private insurance. By law, Medicaid cannot pay
more than Medicare. Medicare reimburses physicians using a fee schedule, the Resource Based Relative
Value Scale. A comparison of the 1993 Medicare Fee Schedule to average Medicaid payments in 1994
shows that Medicaid paid out an amount equal to an average of 77% of the Medicare Fee Schedule.8 In
contrast, typical physician payments by private insurers run from 115% to 120% of the Medicare Fee
Schedule.9 In addition, states have continued to limit physician payment rates; average fees for
physician services rose just 4.6% overall from 1993 to 1998.2

MEDICARE AND MEDICAID COMPARISON

In some ways it is useful to consider Medicare and Medicaid as a combined entity since changes in one
program often dramatically impact the other. Both programs are federally financed (partially for
Medicaid) and are managed by the Health Care Financing Administration (HCFA). They also both
cover elderly and disabled persons, but differ in the range of services offered. Both programs enroll
about the same number of persons (41.4 million in Medicaid and 38.8 million in Medicare in 1998).10
However, Medicare does not offer much in the way of either prescription drug or nursing home
coverage. Therefore, dually eligible people tend to receive hospital and physician services from
Medicare and prescription drug and nursing home services from Medicaid. Figure 1-4 illustrates the
spending pattern differences between Medicaid and Medicare.

Figure 1-4: Medicare versus Medicaid Spending, 19991

$140
$120
$100
$80
$60 Hospitals
Physicians and Clinical Services
$40
Nursing Homes
$20
$0 Drugs
Medicare
Medicaid

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MEDICAID COMPARED TO NATIONAL HEALTH SPENDING

Average annual growth in National Health Expenditures versus Medicaid growth rates are shown below
in Figure 1-5.

Figure 1-5: National versus Medicaid Average Growth Rates1

10%
8.9%
7.7% 7.5%
8%

5.6% 5.4%
6%
Growth

5.4% 5.6%
5.2% 5.0%
4% 4.8%

National
2%
Medicaid

0%
1995 1996 1997 1998 1999

Over the last decade, both national and Medicaid expenditures for nursing home services have risen
steadily. However, the rate of growth for both national and Medicaid nursing home spending has
declined from 1996 to 1999 (except for a significant increase in Medicaid spending from 1998 to 1999).1
See Figures 1-6a and 1-6b below. Most of this decline in the national growth rate was due to
restructuring of the Medicare Prospective Payment System (PPS) for skilled nursing home payments.

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Figure 1-6a: National and Medicaid Nursing Home Expenditures1

$100
$88.0 $90.0
$85.1
$79.9
$80 $74.6
National
Medicaid
$60
Billions

$39.8 $40.7 $42.4


$35.4 $37.8
$40

$20

$0
1995 1996 1997 1998 1999

Figure 1-6b: National versus Medicaid Nursing Home Expenditures, Growth Rates1

10%
9.1%
National
8% 7.1%
6.5% Medicaid

6%
6.6%
4.1%
5.3% 3.5%
4%
4.0%
2%
2.3% 2.3%

0%
1995 1996 1997 1998 1999

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National hospital spending rose somewhat in the latter half of the 1990’s, while Medicaid hospital
spending grew significantly from 1998 to 1999, approximately 9.4%.1 See Figures 1-7a and 1-7b.

Figure 1-7a: National and Medicaid Hospital Expenditures1

$450
$377.1 $390.9
$400 $367.7
$343.6 $355.9
$350
$300
National
Billions

$250 Medicaid
$200
$150
$100 $56.8 $58.0 $60.8 $66.5
$54.3
$50
$0
1995 1996 1997 1998 1999

Figure 1-7b: National versus Medicaid* Hospital Expenditures, Growth Rates1

10%
9.4%

8%

6% 4.8%
Billions

4.3% 4.5%
3.3%
4%

3.4% 3.6% 3.7%


2% 2.6% National
2.2%
Medicaid
0%
1995 1996 1997 1998 1999

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National home health spending rose consistently in the early 1990’s and then dropped after Medicare
changed reimbursement procedures and payment levels in 1997. See Figures 1-8a and 1-8b below.
Spending for home health in the Medicaid program is increasing and is expected to continue to increase
with the implementation of the Olmstead law. The Olmstead ruling requires states to provide
community-based health services to disabled persons, when feasible.

Figure 1-8a: National versus Medicaid Home Health Care Expenditures1

$40
$33.6 $34.5 $33.5 $33.1
$30.5
$30

National
Billions

$20 Medicaid

$10
$4.5 $4.9 $5.4 $5.6
$4.2

$0
1995 1996 1997 1998 1999

Figure 1-8b: National versus Medicaid Home Health Care Expenditures, Growth Rate1

20%
17.1%
National
15%
Medicaid
10.1%
8.9%
10%
11.7%
10.3%
5% 2.8%
6.2%
4.1%
0%

-3.0% -1.4%
-5%
1995 1996 1997 1998 1999

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The national rate of spending growth for prescription drugs rose rapidly in the 1990’s. The Medicaid
spending rate for prescription drugs also rose rapidly in the 1990’s, even more rapidly than the national
trend. See Figures 1-9a and 1-9b below. As the mix of enrollees increasingly changes from adults and
children towards the aged and disabled, spending for prescription drugs is likely to continue to rise
(since the latter group has greater need for medication).

Figure 1-9a: National versus Medicaid Prescription Drug Expenditures1

$120
$99.6
$100
$85.2
$80 $75.1
$67.2 National
$60.8
Billions

$60 Medicaid

$40

$14.4 $17.1
$20 $9.7 $10.9 $12.3

$0
1995 1996 1997 1998 1999

Figure 1-9b: National versus Medicaid Prescription Drug Expenditures, Growth Rate1

25%

18.7%
20%
16.7%

13.7%
15% 12.4% 16.9%
12.0%
Rate

13.4%
10% 11.9%
11.2%
10.5%

5% National Rate
Medicaid Rate
0%
1995 1996 1997 1998 1999

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SUMMARY

Medicaid expenditure trends for the latter half of the 1990’s were:

• The rate of growth in Medicaid spending was generally higher than the overall national growth
rate. Compared to a national growth rate between 4.8% and 5.6% throughout the latter half of
the 1990’s, the rate of growth in Medicaid was between 5.0% and 8.9%. The Medicaid growth
rate rose significantly from 1997 to 1999 due to program expansions.

• Most Medicaid spending is for long-term care services. Home health and personal care service
expenditures are growing most rapidly in this sector.

• Spending continues to be driven primarily by the aged, blind, and disabled population.

• Spending growth rates for hospital services remained fairly flat in the Medicaid program,
paralleling national rates, until 1999, when Medicaid experienced a major spending increase.

• Pharmacy spending is increasing rapidly in Medicaid and nationally; however, pharmacy costs
still remain a relatively small proportion of total spending.

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REFERENCES

1 National Health Expenditures by Type of Service and Source of Funds: Calendar Years 1960-99.
Health Care Financing Administration, Office of the Actuary, National Health Statistics Group.
www.hcfa.gov/stats/nhe-oact/tables/nhe99.csv. Figures for Medicaid do not include Medicaid
SCHIP Expansion or Part B premium payments made by Medicaid.

2 Bruen B and Holahan J. Medicaid and the Uninsured. Slow Growth in Medicaid Spending
Continues in 1997. Issue Paper. The Henry J. Kaiser Foundation, November 1999.

3 Medicaid Statistics, Table 5. Medicaid Vendor Payments by Type of Service.


www.hcfa.gov/medicaid/msis/2082-5.htm. HCFA, CMSO, HCFA-2082 Report.

4 Medicaid Statistics, Table 1. Medicaid Beneficiaries, Vendor, Medical Assistance and


Administrative Payments. www.hcfa.gov/medicaid/msis/2082-1.htm. HCFA, CMSO, HCFA-2082
Report.

5 Medicaid Statistics, Table 3. Medicaid Beneficiaries, and Vendor Payments by Basis of Eligibility,
www.hcfa.gov/medicaid/msis/2082-3.htm. HCFA, CMSO, HCFA-2082 Report.

6 National Summary of Medicaid Managed Care Programs and Enrollment. June 30, 1999. Managed
Care Trends. www.hcfa.gov/medicaid/trends99.htm.

7 Iglehart JK. The American Health Care System. New England Journal of Medicine
1999;340(5):403-8.

8 Norton SA. 1994. The Declining Gap between Medicaid and Medicare Physician Fees. In
Winterbottom C, Liska DW, and Obermaier KM. State-Level Databook on Health Care Access and
Financing, Health Tracking, 2nd ed., Robert Wood Johnson Foundation, 1995, pg. 138.

9 Over 100 private insurers interviewed by The Lewin Group, 2000-2001.

10 1999 HCFA Statistics. Health Care Financing Administration. U.S. Department of Health and
Human Services.

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Section 2:
Medicaid Managed Care

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MEDICAID MANAGED CARE ENROLLMENT

Since 1981, when Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers to
increase access to managed care and test innovative health care financing and delivery options, enrollment in
Medicaid managed care has grown considerably. Over the past five years, managed care enrollment as a
percentage of total Medicaid enrollment has increased by 140 percent (i.e., from 23.2% to 55.6%). In 1999, more
than half of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30,
1999, all but two states (Alaska and Wyoming) were enrolling Medicaid beneficiaries in some type of managed
care plan.

Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment

100%

80% 46.4% 44.4%


% of Enrollment

52.2%
59.9%
70.6%
60% 76.8%
85.6%
40% 55.6%
53.6%
47.8%
20% 40.1%
29.4%
23.2%
14.4%
0%
1993 1994 1995* 1996 1997 1998 1999

Managed Care Fee-for-Service

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.
*Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary, which used HCFA 2082 data to
calculate average Medicaid enrollees over 1995. The managed care population differs from the 11,619,929 reported in the 1995 report as
the number represented enrollment of some beneficiaries in more than one plan.

TYPES OF MEDICAID MANAGED CARE PLANS

Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care plans:

• Health Insuring Organization (HIO): an entity that provides for or arranges for the provision of care and
contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

• Comprehensive Managed Care Organization (Comp-MCO): a health maintenance organization with a


contract under §1876 or a Medicare-Choice organization, a provider sponsored organization or any private or
public organization which meets the requirements of §1902 (w). They provide comprehensive services to
commercial and/or Medicare, as well as Medicaid enrollees.

• Medicaid-only Managed Care Organization (Mcaid-MCO): a Medicaid-only MCO that provides


comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

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• Prepaid Health Plan (PHP): an entity that provides less than comprehensive services on an at-risk basis or
one that provides any benefit package on a non-risk basis.

• Primary Care Case Management (PCCM): a provider (usually a physician, physician group practice, or an
entity employing or having other arrangements with such physicians, but sometimes also including nurse
practitioners, nurse midwives, or physician assistants) who contracts to locate, coordinate, and monitor
covered primary care (and sometimes additional services). This category includes any PCCMs and those
PHPs that act as PCCMs.

• “Other” Managed Care Arrangement: arrangements used if the plan is not considered a PCCM, PHP,
Comprehensive MCO, Medicaid-only MCO, or HIO.

The most utilized of these plans are Comprehensive MCO and Prepaid Health Plans.

Table 2-1: Medicaid Managed Care Plans

Number of Number of
Plan Type Plans Enrollees
Health Insuring Organization 6 365,738
Comprehensive Managed Care Organization 237 8,488,107
Comprehensive Medicaid-only Managed Care Organization 136 3,524,049
Primary Care Case Management 60 4,274,456
Prepaid Health Plan 129 8,104,413
Other 13 20,192
Total 581 24,776,955*

* Total number of enrollees includes 7,020,352 individuals enrolled in more than one managed care plan type.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

The following tables provide an overview of Medicaid managed care enrollment at the state level.

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Medicaid Managed Care Enrollment, As of June 30, 1999


Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 31,940,188 17,756,603 55.59% -
Alabama 513,863 377,952 73.55% 17
Alaska 70,764 0 0.00% 51
Arizona 401,066 363,662 90.67% 6
Arkansas 388,048 232,123 59.82% 30
California 4,972,673 2,540,902 51.10% 36
Colorado 234,753 216,357 92.16% 5
Connecticut 322,181 230,217 71.46% 19
Delaware 88,186 68,869 78.10% 12
District of Columbia 122,918 75,499 61.42% 26
Florida 1,512,216 912,045 60.31% 28
Georgia 848,618 638,082 75.19% 15
Hawaii 152,757 120,246 78.72% 11
Idaho 87,203 31,184 35.76% 42
Illinois 1,312,599 158,888 12.10% 47
Indiana 500,671 331,363 66.18% 22
Iowa 206,822 176,487 85.33% 8
Kansas 180,523 95,868 53.11% 34
Kentucky 539,810 324,447 60.10% 29
Louisiana 771,092 44,741 5.80% 49
Maine 168,092 23,720 14.11% 46
Maryland 501,000 347,937 69.45% 21
Massachusetts 891,428 575,186 64.52% 23
Michigan 1,130,608 1,130,608 100.00% 1
Minnesota 438,133 268,360 61.25% 27
Mississippi 485,716 200,347 41.25% 39
Missouri 714,392 276,628 38.72% 41
Montana 69,738 69,738 100.00% 2
Nebraska 171,723 122,006 71.05% 20
Nevada 92,996 36,945 39.73% 40
New Hampshire 71,407 5,812 8.14% 48
New Jersey 611,589 356,956 58.37% 31
New Mexico 284,705 208,528 73.24% 18
New York 2,255,694 659,569 29.24% 43
North Carolina 831,708 689,104 82.85% 9
North Dakota 43,389 23,886 55.05% 33
Ohio 975,415 244,888 25.11% 44
Oklahoma 372,501 193,902 52.05% 35
Oregon 378,894 308,798 81.50% 10
Pennsylvania 1,304,427 1,004,601 77.01% 13
Puerto Rico 997,474 764,068 76.60% 14
Rhode Island 134,018 85,900 64.10% 24
South Carolina 498,147 23,149 4.65% 50
South Dakota 68,195 50,220 73.64% 16
Tennessee 1,312,969 1,312,969 100.00% 3
Texas 1,788,569 352,062 19.68% 45
Utah 132,566 118,601 89.47% 7
Vermont 113,925 65,692 57.66% 32
Virgin Islands 19,359 0 0.00% 51
Virginia 460,373 292,214 63.47% 25
Washington 707,245 706,202 99.85% 4
West Virginia 256,869 111,532 43.42% 38
Wisconsin 395,336 187,543 47.44% 37
Wyoming 34,825 0 0.00% 51
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional
Medicaid eligibility standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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Pharmaceutical Benefits 2000

Pharmaceutical Benefits Under Managed Care Plans


Medicaid Where do managed care recipients Special requirements
Managed Care receive pharmacy benefits? for pharmacy benefits
State Enrollment (State, Managed Care Plan, Both) in managed care?
Alabama 377,952 N/A N/A
Alaska 0 - -
Arizona* 363,662 - -
Arkansas 232,123 State None
California 2,540,902 Both Guidelines, contractual
Colorado 216,357 Managed Care Plan N/A
Connecticut 230,217 Managed Care Plan Contractual
Delaware 68,869 State N/A
District of Columbia 75,499 Both None
Florida 912,045 Managed Care Plan Contractual
Georgia 638,082 N/A N/A
Hawaii 120,246 Both Guidelines, contractual
Idaho 31,184 State N/A
Illinois 158,888 Managed Care Plan Contractual
Indiana 331,363 Managed Care Plan Statutes, contractual
Iowa 176,487 State None
Kansas 95,868 Managed Care Plan Contractual
Kentucky 324,447 Both Contractual
Louisiana 44,741 State N/A
Maine 23,720 State None
Maryland 347,937 Both Regulations
Massachusetts 575,186 Managed Care Plan Contractual
Michigan 1,130,608 Both Contractual
Minnesota 268,360 Managed Care Plan Contractual
Mississippi 200,347 Both Contractual
Missouri 276,628 Managed Care Plan Guidelines, contractual
Montana 69,738 State None
Nebraska 122,006 State Statutes, regulations, guidelines, contractual
Nevada 36,945 Both Contractual
New Hampshire 5,812 State None
New Jersey 356,956 Managed Care Plan Guidelines
New Mexico 208,528 Managed Care Plan N/A
New York 659,569 State Statutes, FFS program
North Carolina 689,104 State None
North Dakota 23,886 State None
Ohio 244,888 Managed Care Plan Statutes
Oklahoma 193,902 Managed Care Plan Contractual
Oregon 308,798 Both Guidelines, contractual
Pennsylvania 1,004,601 Managed Care Plan Contractual
Rhode Island 85,900 Managed Care Plan N/A
South Carolina 23,149 Managed Care Plan Contractual
South Dakota 50,220 N/A N/A
Tennessee* 1,312,969 Managed Care -
Texas 352,062 State N/A
Utah 118,601 State (Carve-out) N/A
Vermont 65,692 State None
Virginia 292,214 Managed Care Plan Contractual
Washington 706,202 Both Contractual
West Virginia 111,532 State N/A
Wisconsin 187,543 Managed Care Plan Statutes, regulations, contractual
Wyoming 0 - -
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care. As
reported by state drug program administrators in the 2000 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 1997-1999


State 1997 1998 1999
National Total 15,345,502 16,573,996 17,756,603
Alabama 407,643 362,272 377,952
Alaska 0 0 0
Arizona 349,142 368,344 363,662
Arkansas 159,458 186,215 232,123
California 1,854,294 2,246,406 2,540,902
Colorado 184,000 215,936 216,357
Connecticut 231,966 220,803 230,217
Delaware 65,061 62,010 68,869
District of Columbia 80,721 51,022 75,499
Florida 896,559 915,554 912,045
Georgia 560,771 673,528 638,082
Hawaii 135,200 131,761 120,246
Idaho 32,428 30,866 31,184
Illinois 187,048 175,649 158,888
Indiana 220,000 233,065 331,363
Iowa 88,282 190,692 176,487
Kansas 94,430 84,437 95,868
Kentucky 268,205 325,233 324,447
Louisiana 40,469 40,729 44,741
Maine 12,511 16,295 23,720
Maryland 347,640 306,474 347,937
Massachusetts 461,989 532,971 575,186
Michigan 865,434 752,568 1,130,608
Minnesota 169,329 225,498 268,360
Mississippi 81,255 153,562 200,347
Missouri 264,496 252,097 276,628
Montana 62,004 66,331 69,738
Nebraska 93,085 110,606 122,006
Nevada 26,376 35,089 36,945
New Hampshire 9,102 7,368 5,812
New Jersey 384,644 376,839 356,956
New Mexico 139,337 193,818 208,528
New York 660,725 634,233 659,569
North Carolina 351,043 559,035 689,104
North Dakota 24,295 22,045 23,886
Ohio 352,833 292,819 244,888
Oklahoma 222,818 154,270 193,902
Oregon 312,345 299,826 308,798
Pennsylvania 870,365 904,701 1,004,601
Puerto Rico 702,250 813,791 764,068
Rhode Island 70,944 74,446 85,900
South Carolina 14,311 15,823 23,149
South Dakota 41,542 43,834 50,220
Tennessee 1,188,570 1,268,769 1,312,969
Texas 275,951 437,898 352,062
Utah 93,785 112,803 118,601
Vermont 22,946 52,153 65,692
Virgin Islands 0 0 0
Virginia 306,804 299,266 292,214
Washington 730,052 718,023 706,202
West Virginia 125,521 131,349 111,532
Wisconsin 205,523 194,874 187,543
Wyoming 0 0 0
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional
Medicaid eligibility standards.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1997; 1998; 1999. DHHS, HCFA, Office of
Managed Care.

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Pharmaceutical Benefits 2000

Medicaid Managed Care Plan Type, As of June 30, 1999


Comprehensive
Comprehensive Medicaid-only
State HIO MCO MCO PCCM PHP Other
National Total 6 237 136 60 129 13
Alabama 0 1 0 24 9 0
Alaska - - - - - -
Arizona 0 2 30 0 1 0
Arkansas 0 0 0 1 1 0
California 5 18 13 2 9 5
Colorado 1 4 1 1 1 0
Connecticut 0 4 1 0 0 0
Delaware 0 3 0 0 0 0
District of Columbia 0 7 1 0 0 0
Florida 0 16 0 3 1 0
Georgia 0 0 0 1 2 0
Hawaii 0 8 2 0 0 0
Idaho 0 0 0 1 0 0
Illinois 0 7 3 4 0 0
Indiana 0 1 2 1 0 0
Iowa 0 5 0 1 1 0
Kansas 0 0 1 1 0 0
Kentucky 0 0 2 1 1 0
Louisiana 0 0 0 1 0 0
Maine 0 1 0 1 0 0
Maryland 0 3 5 0 0 0
Massachusetts 0 3 2 1 1 0
Michigan 0 15 13 1 49 2
Minnesota 0 8 1 0 0 1
Mississippi 0 3 0 1 0 0
Missouri 0 6 4 0 0 0
Montana 0 2 0 1 1 0
Nebraska 0 2 0 1 1 0
Nevada 0 4 0 0 0 0
New Hampshire 0 2 0 0 0 0
New Jersey 0 4 2 0 0 0
New Mexico 0 3 0 0 0 0
New York 0 16 16 1 8 2
North Carolina 0 5 0 2 1 0
North Dakota 0 1 0 1 0 0
Ohio 0 8 3 0 0 0
Oklahoma 0 4 0 1 0 0
Oregon 0 8 3 0 0 0
Pennsylvania 0 5 8 2 15 0
Puerto Rico 0 4 0 0 0 0
Rhode Island 0 4 0 0 0 0
South Carolina 0 0 1 0 0 2
South Dakota 0 0 0 1 0 0
Tennessee 0 0 9 0 2 0
Texas 0 6 6 1 0 0
Utah 0 5 0 0 8 0
Vermont 0 2 0 0 0 0
Virginia 0 7 0 1 0 0
Washington 0 9 2 1 15 0
West Virginia 0 3 0 1 0 0
Wisconsin 0 18 5 0 2 1
Wyoming - - - - - -
HIO=Health Insuring Organization; Comprehensive MCO=Comprehensive Managed Care Organization; Comprehensive Medicaid-only
MCO=Comprehensive Medicaid-only Managed Care Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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Pharmaceutical Benefits 2000

Medicaid Managed Care Enrollment by Plan Type,


As of June 30, 1999
Comprehensive Comprehensive
State HIO MCO Medicaid-only MCO PCCM PHP Other
National Total 365,738 8,488,107 3,524,049 4,274,456 8,104,413 20,192
Alabama - 39,597 - 310,584 637,654 -
Alaska - - - - - -
Arizona - 22,889 361,273 - 24,431 -
Arkansas - - - 194,753 232,122 -
California 365,498 938,125 1,208,314 26,617 333,160 2,279
Colorado 240 37,880 43,029 50,214 216,357 -
Connecticut - 193,432 36,785 - - -
Delaware - 68,869 - - - -
District of Columbia - 73,640 1,859 - - -
Florida - 446,538 - 465,507 41,660 -
Georgia - - - 613,560 24,522 -
Hawaii - 191,086 52,356 - - -
Idaho - - - 31,184 - -
Illinois - 98,956 41,505 - 18,427 -
Indiana - 69,194 42,848 219,321 - -
Iowa - 47,048 - 45,570 176,487 -
Kansas - - 22,402 73,466 - -
Kentucky - - 158,628 165,819 - -
Louisiana - - - 44,741 - -
Maine - 5,569 - 18,151 - -
Maryland - 238,240 109,697 - - -
Massachusetts - 117,715 23,808 433,663 627,894 -
Michigan - 521,790 228,830 - 1,130,608 1,124
Minnesota - 264,231 3,885 - - 244
Mississippi - 10,216 - 190,131 - -
Missouri - 186,109 90,519 - - -
Montana - 1,965 - 39,847 69,738 -
Nebraska - 28,052 - 24,345 122,006 -
Nevada - 36,945 - - - -
New Hampshire - 5,812 - - - -
New Jersey - 261,804 95,152 - - -
New Mexico - 2,420,860 - - - -
New York - 359,379 235,065 4,768 59,531 826
North Carolina - 38,881 - 517,511 132,712 -
North Dakota - 718 - 23,168 - -
Ohio - 142,235 102,653 - - -
Oklahoma - 98,140 - 95,762 - -
Oregon - 206,651 23,940 134,279 698,307 -
Pennsylvania - 414,698 428,682 154,468 713,145 -
Puerto Rico - 764,068 - - - -
Rhode Island - 85,900 - - - -
South Carolina - - 7,454 - - 15,695
South Dakota - - - 50,220 - -
Tennessee - 1,312,969 - - 1,312,969
Texas - 107,932 107,929 136,201 - -
Utah - 73,921 - - 118,601 -
Vermont - 65,692 - - - -
Virginia - 150,067 - 142,147 - -
Washington - 323,079 93,221 3,805 1,413,447 -
West Virginia - 46,878 - 64,654 - -
Wisconsin - 182,669 4,215 - 635 24
Wyoming - - - - - -
*The total number of enrollees includes 7,020,352 individuals who were enrolled in more than one managed care plan. It also includes
individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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Pharmaceutical Benefits 2000

Medicaid Managed Care Enrollment by Payment Arrangement,


As of June 30, 1999
State Fee-For-Service (FFS) Fully Capitated (FUL) Partially Capitated (PAR)
National Total 4,892,041 17,844,439 2,040,475
Alabama 310,584 677,251 -
Alaska - - -
Arizona - 408,593 -
Arkansas 194,753 232,122 -
California 26,617 2,847,376 -
Colorado 50,214 297,506 -
Connecticut - 230,217 -
Delaware - 68,869 -
District of Columbia - 75,499 -
Florida 465,489 488,216 -
Georgia 613,560 2,408 22,114
Hawaii - 243,442 -
Idaho 31,184 - -
Illinois - 150,554 8,334
Indiana 219,321 112,042 -
Iowa 45,570 223,535 -
Kansas 73,466 22,402 -
Kentucky 165,819 158,628 -
Louisiana 44,741 - -
Maine 18,151 5,569 -
Maryland - 347,937 -
Massachusetts 433,663 141,523 627,894
Michigan - 751,744 1,130,608
Minnesota 244 268,116 -
Mississippi 190,131 10,216 -
Missouri - 276,628 -
Montana 39,847 71,703 -
Nebraska 24,345 28,052 122,006
Nevada - 36,945 -
New Hampshire - 5,812 -
New Jersey - 356,956 -
New Mexico - 208,528 -
New York 4,768 630,887 23,914
North Carolina 517,511 171,593 -
North Dakota 23,168 718 -
Ohio - 244,888 -
Oklahoma - 98,140 95,762
Oregon 134,279 928,898 -
Pennsylvania 154,468 1,556,525 -
Puerto Rico - 764,068 -
Rhode Island - 85,900 -
South Carolina 5,852 7,454 9,843
South Dakota 50,220 - -
Tennessee - 2,625,938 -
Texas 136,201 215,861 -
Utah - 192,522 -
Vermont - 65,692 -
Virginia 142,147 150,067 -
Washington 711,050 1,122,502 -
West Virginia 64,654 46,878 -
Wisconsin 24 187,519 -
Wyoming - - -
Individual state totals will not sum to total managed care enrollment (page 2-5) because state totals include individuals enrolled in more
than one plan type including dental, mental, and long-term care.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1999. DHHS, HCFA, Office of Managed Care.

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MEDICAID MANAGED CARE WAIVERS

In 1981, Congress authorized states to implement Section 1915b and Section 1115 Medicaid waivers to increase
access to managed care and test innovative health care financing and delivery options. The U.S. Department of
Health and Human Services granted these waivers to allow states to “waive” requirements in Sections 1902 and
1903 of the Social Security Act and “mandate” enrollment of Medicaid eligibles in managed care programs.

SECTION 1915B “FREEDOM OF CHOICE” WAIVERS

Section 1915b waivers are granted to give states the authority to conduct Medicaid programs outside of the scope
of the Medicaid statute, allowing them to waive freedom of choice, statewide access to care, and comparability
requirements under Section 1902 of the Social Security Act. With a 1915b waiver, a state can require mandatory
enrollment of Medicaid recipients in managed care plans. 1915b waivers cannot negatively impact beneficiary
access, quality of care of services, and must be cost-effective (cost must be less than the Medicaid program
would cost without the waiver). Section 1915b waivers are typically limited to a targeted geographical area or
population, are approved for an initial period of two years, and can be renewed in two-year increments if the state
reapplies.

Four options for 1915b waivers exist; each is governed by a different subsection(s) of Section 1915b:

• Subsection 1 - Case Management: States are allowed to implement case management systems which can be
as simple as requiring each beneficiary to choose a primary care provider or as comprehensive as mandating
enrollment in a prepaid health plan.
• Subsection 2 - Central Broker: States are allowed to act as a central broker in assisting medical assistance
eligibles in selecting among competing health care plans, if such a restriction does not substantially impair
access to medically necessary services of adequate quality.
• Subsection 3 - Shared Cost Saving: States are allowed to share (through provision of additional services) cost
savings (resulting from use by the recipient of more cost-effective medical care) with recipients of medical
assistance under the State plan.
• Subsection 4 - Restrict Providers: States can limit the number of providers of certain services. These waivers
are sometimes referred to as selective contracting waivers and were gaining in popularity. Recently approved
1915b(4) waivers included programs to restrict the number of providers of transportation services, organ
transplants, and inpatient obstetrical care.
Refer to the table on page 2-13 for a listing of 1915b waivers.

Although Section 1915b waivers allow states to increase access to managed care plans, states are still limited
under Federal regulation and cannot use them to serve beneficiaries beyond Medicaid State Plan Eligibility or
change their benefits package. In order to expand their Medicaid programs even further than under 1915b
waivers, states apply for Section 1115 research and demonstration waivers.

SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

Section 1115 research and demonstration waivers released states from standard Medicaid requirements, allowing
them the flexibility to test substantially new ideas of policy merit. Along with 1915b waivers, 1115 waivers
allowed states to waive freedom of choice, statewide access to care, and comparability requirements. However,
an 1115 waiver also allowed states to provide new and additional services, test new payment methods, offer
benefits to new and expanded populations, and contract with managed care organizations that did not meet the
necessary criteria of Section 1903 of the Social Security Act.

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Pharmaceutical Benefits 2000

To receive approval of a Section 1115 waiver, states submit a proposal to HCFA for discussion and review.
Once operational, states allow formal evaluations of the research and public policy value of the programs and to
demonstrate that their programs do not exceed costs which would have otherwise occurred under traditional
Medicaid programs (i.e., states must demonstrate budget neutrality). Section 1115 waivers are usually granted
for a five-year period and each state must request for continuation. For example, Arizona operated its program
under an 1115 waiver for 17 years.

Currently, there are 20 Medicaid programs with 1115 waiver approvals. Arizona, Arkansas, California, Delaware,
District of Columbia, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, Montana, New York,
Ohio, Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin have actually implemented their
1115 waivers. Refer to the table on page 2-16 for a listing of implemented 1115 waivers.

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1915(b) Waivers, As of June 30, 1999

1915b
State Program(s) Approved Statutes Utilized Expiration
Maternity Waiver Program 1 9/30/99
Alabama Partnership Hospital Program 1, 4 3/29/01
st
Patient 1 1, 3, 4 6/29/01
Alaska None -- --
Arizona None -- --
Arkansas Non-Emergency Transportation 1 2/29/00
CALOPTIMA 1, 2, 4 5/06/00
Health Plan of San Mateo 1, 2, 3, 4 7/4/00
Hudman 4 7/21/00
Managed Care Network 1, 3, 4 11/25/99
Medi-Cal Mental Health Care Field Test 4 6/25/00
Medi-Cal Specialty Mental Health Services Consolidation 4 10/4/99
Partnership Health Plan of California 1, 2, 4 2/16/00
California
Primary Care Case Management Program 1, 2, 3, 4 8/09/01
Sacramento Geographic Managed Care – Medical 1, 2, 4 11/16/99
San Diego Geographic Managed Care 1, 2, 4 10/16/00
Santa Barbara Health Initiative 1, 2, 4 1/17/00
Santa Cruz County Health Option (SCCHO) 1, 2, 4 11/19/00
Selective Provider Contracting Program 4 12/12/01
Two-Plan Model Program 1, 2, 3, 4 12/16/00
Mental Health Capitation Program 1, 3, 4 3/8/00
Colorado
Managed Care Program 1, 2 2/28/00
Connecticut HUSKY A 1, 4 12/20/99
Delaware None -- --
District of Columbia DC Managed Care Program 1, 2, 4 3/31/00
MediPass 1 6/30/99
Florida Prepaid Mental Health Plan 1, 4 6/30/01
Sub-Acute Inpatient Psychiatric Program 3, 4 3/22/00
Georgia Better Health Care 1 7/01/00
Georgia
Mental Health/Mental Retardation Services 1, 4 2/19/00
Hawaii None -- --
Idaho Healthy Connections 1, 2 11/15/99
Illinois None -- --
Indiana Hoosier Healthwise 1 1/26/00
Iowa Plan for Behavioral Health 1, 3, 4 12/31/00
Iowa
Iowa Medicaid Managed Health Care 1, 2 5/9/01
KMMC: Prime Care Kansas 1, 2, 4 6/26/00
Kansas
KMMC: Health Connect 1, 2, 4 6/26/00
Human Services Transportation 4 10/30/00
Kentucky Kentucky Patient Access and Care System (KENPAC) 1 4/13/00
Kentucky Access 1, 3, 4 11/24/99

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Pharmaceutical Benefits 2000

1915b
State Program(s) Approved Statutes Utilized Expiration
Louisiana Community Care Program 1 6/28/00
Maine None -- --
Maryland None -- --
Massachusetts None -- --
Comprehensive Health Care Program 1, 2, 4 12/27/99
Michigan
Specialty Community Mental Health Services 1, 4 9/30/00
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 3/24/01
Mississippi None -- --
Missouri Managed Care Plus (MC+) 1, 2, 4 3/14/00
Mental Health Access Plan 1 6/30/99
Montana
Passport to Health 1 10/25/99
Medicaid Health Connection – MH/SA 1 6/30/99
Nebraska
Nebraska Health Connection – Med/Surg 1, 2 6/30/99
Nevada None -- --
New Hampshire None -- --
New Jersey None -- --
New Mexico SALUD! 1,4 7/1/99
Non-Emergency Transportation 4 1/13/00
New York Southwest Brooklyn Managed Care Demonstration Project 1, 4 8/16/00
The Westchester County Managed Care Program 1, 4 3/31/00
ACCESS II 1 11/29/99
Carolina Access 1 11/29/99
North Carolina Carolina Alternatives 1, 4 6/30/99
Health Care Connection 1 11/29/99
Health Maintenance Organization (HMO) 1 11/29/99
North Dakota North Dakota Access and Care Program 1 5/5/01
Ohio None -- --
Oklahoma None -- --
Oregon Tri-County Metro. Transportation District 4 1/25/01
Family Care Network 1 7/26/01
HealthChoices SE - Behavioral 1, 2, 3, 4 1/26/00
HealthChoices SE – Physical Health 1, 2, 3, 4 1/26/00
Pennsylvania
HealthChoices SW - Behavioral 1, 2, 3, 4 12/31/99
HealthChoices SW – Physical Health 1, 2, 3, 4 12/31/99
Lancaster Community Health Plan 1 7/21/00
Rhode Island None -- --
South Carolina High Risk Channeling Project (HRCP) 1, 3, 4 2/11/01
South Dakota Prime 1, 3 7/1/00
Tennessee None -- --
Lonestar Select I 4 9/3/00
Lonestar Select II 4 8/19/99
Texas HMO - STAR 1, 2, 3, 4 8/31/010
HMO - STAR Plus (+) 1, 2, 3, 4 1/31/00
PCCM - STAR Plus (+) 1, 2, 3, 4 1/31/00

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Pharmaceutical Benefits 2000

1915b
State Program(s) Approved Statutes Utilized Expiration
Choice of Health Care Delivery 1, 2, 4 2/16/01
Utah
Prepaid Mental Health Program 4 10/28/99
Vermont None -- --
Medallion 1 9/24/99
Virginia
Medallion II 1, 4 9/27/00
Mental Health Services 1, 4 11/7/99
Washington Healthy Options 1, 4 2/24/01
Hospital Selective Contracting 4 12/31/00
Mountain Health Care Trust 1, 4 8/26/99
West Virginia
Physician Assured Access System (PAAS) 1 9/5/99
Wisconsin None -- --
Wyoming Hospital Inpatient Selective Contracting 4 3/15/01
Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Department
of Health and Human Services, Health Care Financing Administration, Office of Managed Care.

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Pharmaceutical Benefits 2000

Section 1115 Research and Demonstration Waivers

State Program Implemented Expiration


Alabama Bay Health Plan 5/1/97 10/1/99
Arizona Health Care Cost Containment System
Arizona 10/1/82 9/30/99
(AHCCCS)
On Lock Senior Health Services 11/1/83 9/30/00
Senior Care Action Network 1/1/85 4/30/00
California
Sutter Senior Care 5/1/94 9/30/00
Centers For Elders Independence 4/1/95 9/30/00
Delaware Diamond State Health Plan 1/1/96 12/31/03
District of Columbia Health Services for Children w/Spec. Needs 2/1/96 12/1/99
Hawaii Hawaii QUEST 8/1/94 3/31/02
Kentucky Kentucky Partnerships 11/1/97 10/31/02
Maryland Health Choice 7/1/97 6/1/02
Massachusetts Mass Health 7/1/97 4/30/01
Minnesota Senior Health Options Program (MSHO) 3/1/97 2/28/02
Minnesota MinnesotaCare Program for Families and Children 7/1/95 6/30/02
Prepaid Medical Assistance Program Plus (PMAP+) 7/1/85 6/30/02
Missouri Managed Care Plus (MC+) 9/1/95 3/14/00
Montana HMO 2/1/96 1/31/04
New York New York State Managed Care Program 10/1/97 7/14/02
Ohio Ohio 1115 (TANF & TANF-related) 7/1/96 6/30/01
SoonerCare Choice PCCM Model 1/1/96 12/31/00
Oklahoma
SoonerCare Plus MCO Model 1/1/96 12/31/00
Oregon Oregon Health Plan 2/1/94 1/31/02
Rhode Island Rite Care 8/1/94 7/31/02
Tennessee TennCare 1/1/94 12/31/01
Vermont Vermont Health Access 1/1/96 12/31/01
Wisconsin WI Partnership Program 1/1/96 N/A
Source: 1999 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 1999. U.S. Department
of Health and Human Services, Health Care Financing Administration, Office of Managed Care; Comprehensive Health Care Reform
Demonstrations (12/8/00). Available at http://www.hcfa.gov/medicaid/ord-demo.htm. Accessed December 2000.

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Section 3:
State Characteristics

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Pharmaceutical Benefits 2000

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Pharmaceutical Benefits 2000

Age Demographics, 1999


Total State Percent Ages Percent Percent Percent
State Population 20 and under Ages 21-44 Ages 45-64 Ages 65+
National Total 271,742,826 30.8% 35.9% 21.4% 11.9%
Alabama 4,200,926 27.7% 35.5% 24.0% 12.8%
Alaska 646,842 38.0% 38.7% 18.4% 4.9%
Arizona 4,905,332 33.2% 36.1% 19.7% 11.0%
Arkansas 2,562,587 30.1% 35.0% 19.9% 15.0%
California 33,375,150 32.2% 37.9% 19.6% 10.3%
Colorado 3,970,806 28.8% 42.1% 20.2% 8.9%
Connecticut 3,283,332 29.2% 32.8% 24.8% 13.1%
Delaware 783,012 31.2% 35.5% 19.2% 14.0%
District of Columbia 511,711 23.2% 41.8% 20.1% 14.8%
Florida 14,677,912 26.4% 34.1% 21.2% 18.3%
Georgia 7,666,432 31.1% 36.5% 22.8% 9.7%
Hawaii 1,200,863 30.2% 35.7% 20.4% 13.6%
Idaho 1,274,230 34.7% 33.7% 21.2% 10.4%
Illinois 12,294,861 33.1% 36.4% 19.6% 10.8%
Indiana 5,839,738 30.8% 35.2% 22.6% 11.4%
Iowa 2,837,156 30.7% 33.8% 21.1% 14.4%
Kansas 2,616,318 31.4% 33.6% 19.7% 15.3%
Kentucky 3,864,679 29.0% 33.9% 24.9% 12.1%
Louisiana 4,310,285 31.7% 35.1% 21.5% 11.6%
Maine 1,266,498 27.8% 33.9% 25.5% 12.9%
Maryland 5,046,171 27.2% 37.7% 21.8% 13.2%
Massachusetts 6,116,806 29.3% 36.5% 21.5% 12.7%
Michigan 10,040,679 33.3% 35.2% 19.9% 11.6%
Minnesota 4,833,278 34.1% 35.8% 19.4% 10.7%
Mississippi 2,761,422 32.6% 35.8% 19.0% 12.6%
Missouri 5,405,443 29.5% 36.9% 20.8% 12.7%
Montana 924,582 33.7% 34.3% 21.3% 10.7%
Nebraska 1,716,417 33.5% 35.2% 19.2% 12.0%
Nevada 1,862,276 33.2% 36.4% 19.9% 10.5%
New Hampshire 1,224,200 32.9% 33.7% 23.5% 9.9%
New Jersey 8,092,295 29.7% 36.1% 23.3% 10.9%
New Mexico 1,829,164 35.7% 31.6% 20.2% 12.4%
New York 18,420,007 30.5% 35.5% 21.1% 13.0%
North Carolina 7,426,910 28.2% 36.1% 23.2% 12.5%
North Dakota 646,079 33.7% 32.3% 20.2% 13.9%
Ohio 11,224,522 30.0% 35.3% 22.6% 12.1%
Oklahoma 3,268,838 29.2% 33.4% 23.7% 13.7%
Oregon 3,355,739 30.2% 35.2% 23.8% 10.7%
Pennsylvania 11,912,109 28.6% 34.4% 23.4% 13.6%
Rhode Island 968,057 27.9% 34.9% 21.8% 15.4%
South Carolina 3,851,167 29.6% 35.0% 22.8% 12.6%
South Dakota 711,326 32.9% 33.1% 21.2% 12.9%
Tennessee 5,572,470 31.5% 34.1% 23.9% 10.5%
Texas 19,944,736 33.5% 36.7% 20.2% 9.5%
Utah 2,105,665 37.7% 37.3% 17.4% 7.6%
Vermont 593,161 29.4% 37.1% 23.0% 10.5%
Virginia 6,687,894 29.5% 36.4% 22.2% 12.0%
Washington 5,747,382 30.5% 37.5% 22.4% 9.6%
West Virginia 1,750,073 24.8% 33.0% 24.7% 17.5%
Wisconsin 5,128,974 28.4% 36.7% 23.1% 11.8%
Wyoming 486,314 31.3% 34.4% 23.4% 10.9%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

National Pharmaceutical Council 3-3


Pharmaceutical Benefits 2000

Race Demographics, 1999


Total State Percent Percent Percent Percent
State Population White Black Hispanic Other
National Total 271,742,826 71.1% 12.5% 11.7% 4.7%
Alabama 4,200,926 71.1% 27.1% 0.8% 0.9%
Alaska 646,842 73.0% 4.1% 1.8% 21.0%
Arizona 4,905,332 65.5% 2.7% 28.7% 3.0%
Arkansas 2,562,587 79.4% 17.5% 1.4% 1.7%
California 33,375,150 50.3% 6.5% 30.3% 12.9%
Colorado 3,970,806 79.8% 3.0% 14.4% 2.8%
Connecticut 3,283,332 76.3% 11.9% 9.9% 1.9%
Delaware 783,012 69.6% 25.4% 3.5% 1.5%
District of Columbia 511,711 25.9% 64.6% 6.3% 3.2%
Florida 14,677,912 65.4% 15.1% 17.6% 1.9%
Georgia 7,666,432 62.0% 32.9% 3.3% 1.8%
Hawaii 1,200,863 21.7% 2.9% 4.3% 71.1%
Idaho 1,274,230 86.6% 0.3% 10.9% 2.3%
Illinois 12,294,861 71.0% 16.0% 10.1% 2.9%
Indiana 5,839,738 90.9% 5.9% 2.5% 0.8%
Iowa 2,837,156 92.5% 1.9% 3.4% 2.2%
Kansas 2,616,318 84.6% 8.8% 4.1% 2.4%
Kentucky 3,864,679 89.0% 8.9% 1.4% 0.7%
Louisiana 4,310,285 61.5% 35.2% 1.6% 1.8%
Maine 1,266,498 97.9% 0.1% 0.6% 1.4%
Maryland 5,046,171 63.7% 27.0% 3.3% 5.9%
Massachusetts 6,116,806 84.1% 5.8% 6.1% 3.9%
Michigan 10,040,679 80.5% 14.2% 2.8% 2.5%
Minnesota 4,833,278 89.4% 2.5% 2.8% 5.3%
Mississippi 2,761,422 61.9% 37.0% 0.8% 0.4%
Missouri 5,405,443 85.8% 11.0% 1.2% 2.0%
Montana 924,582 88.5% 0.2% 1.8% 9.5%
Nebraska 1,716,417 88.7% 4.5% 4.3% 2.5%
Nevada 1,862,276 70.3% 5.0% 18.5% 6.3%
New Hampshire 1,224,200 96.6% 1.0% 1.0% 1.4%
New Jersey 8,092,295 69.5% 14.3% 12.1% 4.2%
New Mexico 1,829,164 47.6% 1.2% 40.4% 10.9%
New York 18,420,007 64.1% 15.2% 15.2% 5.5%
North Carolina 7,426,910 69.5% 24.1% 3.0% 3.4%
North Dakota 646,079 91.6% 0.2% 0.6% 7.6%
Ohio 11,224,522 86.4% 11.3% 1.4% 0.9%
Oklahoma 3,268,838 79.6% 7.5% 2.6% 10.3%
Oregon 3,355,739 85.9% 2.2% 6.3% 5.6%
Pennsylvania 11,912,109 84.3% 10.5% 3.0% 2.2%
Rhode Island 968,057 84.8% 5.3% 5.9% 4.1%
South Carolina 3,851,167 71.2% 26.8% 0.8% 1.2%
South Dakota 711,326 92.0% 1.6% 0.5% 5.8%
Tennessee 5,572,470 82.2% 15.8% 0.8% 1.1%
Texas 19,944,736 51.1% 12.5% 32.9% 3.4%
Utah 2,105,665 88.7% 1.3% 5.8% 4.2%
Vermont 593,161 97.7% 0.3% 0.4% 1.6%
Virginia 6,687,894 73.0% 19.3% 2.5% 5.2%
Washington 5,747,382 88.8% 1.8% 4.0% 5.4%
West Virginia 1,750,073 94.2% 4.3% 0.4% 1.1%
Wisconsin 5,128,974 88.5% 6.7% 1.9% 3.0%
Wyoming 486,314 92.6% 1.6% 4.4% 1.4%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

3-4 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Insurance Status, 1999


Total State Medicaid Percent Covered Medicare Percent Covered
State Population Population by Medicaid Population by Medicare
National Total 271,742,826 28,485,614 10.5% 35,886,603 13.2%
Alabama 4,200,926 399,999 9.5% 634,905 15.1%
Alaska 646,842 117,183 18.1% 33,271 5.1%
Arizona 4,905,332 438,939 8.9% 598,907 12.2%
Arkansas 2,562,587 264,677 10.3% 429,046 16.7%
California 33,375,150 4,277,170 12.8% 3,782,175 11.3%
Colorado 3,970,806 172,031 4.3% 402,074 10.1%
Connecticut 3,283,332 232,809 7.1% 495,807 15.1%
Delaware 783,012 72,312 9.2% 115,330 14.7%
District of Columbia 511,711 107,897 21.1% 80,852 15.8%
Florida 14,677,912 1,243,033 8.5% 2,901,579 19.8%
Georgia 7,666,432 960,075 12.5% 863,436 11.3%
Hawaii 1,200,863 124,588 10.4% 161,514 13.4%
Idaho 1,274,230 117,487 9.2% 147,135 11.5%
Illinois 12,294,861 1,068,655 8.7% 1,451,317 11.8%
Indiana 5,839,738 321,825 5.5% 758,451 13.0%
Iowa 2,837,156 204,886 7.2% 426,795 15.0%
Kansas 2,616,318 205,572 7.9% 426,411 16.3%
Kentucky 3,864,679 408,724 10.6% 549,788 14.2%
Louisiana 4,310,285 584,223 13.6% 592,659 13.7%
Maine 1,266,498 126,610 10.0% 194,020 15.3%
Maryland 5,046,171 222,431 4.4% 695,125 13.8%
Massachusetts 6,116,806 795,817 13.0% 849,412 13.9%
Michigan 10,040,679 1,138,541 11.3% 1,271,138 12.7%
Minnesota 4,833,278 441,987 9.1% 535,510 11.1%
Mississippi 2,761,422 309,529 11.2% 419,869 15.2%
Missouri 5,405,443 506,629 9.4% 768,233 14.2%
Montana 924,582 130,020 14.1% 113,110 12.2%
Nebraska 1,716,417 168,997 9.8% 220,248 12.8%
Nevada 1,862,276 93,607 5.0% 213,939 11.5%
New Hampshire 1,224,200 103,841 8.5% 128,917 10.5%
New Jersey 8,092,295 499,489 6.2% 932,604 11.5%
New Mexico 1,829,164 326,668 17.9% 262,578 14.4%
New York 18,420,007 2,792,226 15.2% 2,596,260 14.1%
North Carolina 7,426,910 730,203 9.8% 1,073,054 14.4%
North Dakota 646,079 67,742 10.5% 95,936 14.8%
Ohio 11,224,522 1,068,729 9.5% 1,564,115 13.9%
Oklahoma 3,268,838 384,492 11.8% 530,082 16.2%
Oregon 3,355,739 480,716 14.3% 411,036 12.2%
Pennsylvania 11,912,109 1,227,356 10.3% 1,761,765 14.8%
Rhode Island 968,057 89,947 9.3% 160,201 16.5%
South Carolina 3,851,167 355,727 9.2% 582,075 15.1%
South Dakota 711,326 75,786 10.7% 99,149 13.9%
Tennessee 5,572,470 1,083,307 19.4% 644,347 11.6%
Texas 19,944,736 1,895,039 9.5% 2,070,144 10.4%
Utah 2,105,665 151,444 7.2% 179,783 8.5%
Vermont 593,161 93,991 15.8% 69,493 11.7%
Virginia 6,687,894 355,615 5.3% 928,879 13.9%
Washington 5,747,382 684,140 11.9% 593,766 10.3%
West Virginia 1,750,073 273,880 15.6% 349,774 20.0%
Wisconsin 5,128,974 457,212 8.9% 657,393 12.8%
Wyoming 486,314 31,811 6.5% 63,196 13.0%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

National Pharmaceutical Council 3-5


Pharmaceutical Benefits 2000

Income and Employment, 1999


Total State Percent Below 100% Poverty Percent
State Population Level Unemployed
National Total 271,742,826 13.1% 2.0%
Alabama 4,200,926 15.1% 1.9%
Alaska 646,842 10.4% 3.7%
Arizona 4,905,332 16.8% 1.8%
Arkansas 2,562,587 15.0% 1.7%
California 33,375,150 15.6% 2.7%
Colorado 3,970,806 9.3% 1.1%
Connecticut 3,283,332 10.1% 1.5%
Delaware 783,012 10.9% 1.4%
District of Columbia 511,711 23.0% 3.9%
Florida 14,677,912 13.6% 1.5%
Georgia 7,666,432 14.7% 2.3%
Hawaii 1,200,863 10.9% 2.6%
Idaho 1,274,230 13.2% 2.4%
Illinois 12,294,861 11.0% 1.5%
Indiana 5,839,738 9.8% 1.0%
Iowa 2,837,156 8.5% 1.4%
Kansas 2,616,318 9.9% 1.2%
Kentucky 3,864,679 14.6% 2.3%
Louisiana 4,310,285 20.1% 2.0%
Maine 1,266,498 10.8% 2.2%
Maryland 5,046,171 7.7% 1.6%
Massachusetts 6,116,806 9.2% 1.7%
Michigan 10,040,679 11.4% 2.0%
Minnesota 4,833,278 10.7% 1.3%
Mississippi 2,761,422 17.4% 2.4%
Missouri 5,405,443 10.1% 1.8%
Montana 924,582 17.3% 2.9%
Nebraska 1,716,417 13.2% 1.0%
Nevada 1,862,276 11.2% 2.4%
New Hampshire 1,224,200 10.0% 1.6%
New Jersey 8,092,295 9.1% 2.6%
New Mexico 1,829,164 20.4% 2.2%
New York 18,420,007 17.0% 2.4%
North Carolina 7,426,910 14.8% 1.4%
North Dakota 646,079 15.2% 2.4%
Ohio 11,224,522 11.4% 1.7%
Oklahoma 3,268,838 14.8% 1.7%
Oregon 3,355,739 15.1% 3.0%
Pennsylvania 11,912,109 11.6% 2.3%
Rhode Island 968,057 11.7% 1.6%
South Carolina 3,851,167 13.0% 1.5%
South Dakota 711,326 10.7% 1.3%
Tennessee 5,572,470 12.8% 2.2%
Texas 19,944,736 15.3% 1.8%
Utah 2,105,665 9.4% 1.7%
Vermont 593,161 10.0% 2.5%
Virginia 6,687,894 8.9% 1.0%
Washington 5,747,382 9.0% 1.8%
West Virginia 1,750,073 18.0% 2.9%
Wisconsin 5,128,974 8.9% 1.9%
Wyoming 486,314 11.7% 2.3%

Source: The Lewin Group analysis of the Current Population Survey, March 2000 Supplement.

3-6 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Medicaid/Medicare Certified Facilities


Skilled Nursing ICF-MR Home Health Rural Health
State Hospitals Facilities Facilities Agencies Clinics
National Total* 6,052 14,831 6,731 7,160 3,352
Alabama 123 221 8 143 60
Alaska 24 15 0 16 11
Arizona 85 149 11 68 8
Arkansas 96 193 40 182 82
California 468 1,269 1,041 579 225
Colorado 83 202 3 131 43
Connecticut 47 250 122 82 0
Delaware 11 38 2 16 0
District of Columbia 16 19 131 16 0
Florida 239 724 108 318 135
Georgia 182 326 13 99 125
Hawaii 27 41 22 19 1
Idaho 48 82 67 54 35
Illinois 219 658 318 288 198
Indiana 151 496 574 180 52
Iowa 120 300 127 180 134
Kansas 149 264 42 149 156
Kentucky 118 307 12 111 72
Louisiana 175 225 473 255 49
Maine 41 126 28 36 50
Maryland 67 244 5 53 0
Massachusetts 119 505 7 133 0
Michigan 174 389 2 193 153
Minnesota 151 412 272 250 60
Mississippi 104 132 13 62 133
Missouri 141 455 18 171 163
Montana 62 101 2 51 32
Nebraska 96 172 4 70 76
Nevada 42 49 20 36 2
New Hampshire 30 67 1 35 21
New Jersey 107 306 9 54 0
New Mexico 51 69 43 67 14
New York 268 665 750 211 10
North Carolina 135 407 333 165 125
North Dakota 51 88 66 35 80
Ohio 205 893 461 348 17
Oklahoma 151 242 54 188 61
Oregon 63 124 1 60 30
Pennsylvania 252 752 206 328 53
Rhode Island 17 99 5 25 1
South Carolina 76 178 158 78 96
South Dakota 63 89 4 46 55
Tennessee 148 276 83 153 34
Texas 479 1,014 915 860 391
Utah 50 81 14 43 15
Vermont 16 42 2 13 23
Virginia 118 229 19 161 58
Washington 97 266 17 62 61
West Virginia 66 114 62 68 69
Wisconsin 142 369 41 131 65
Wyoming 27 34 2 39 18

*National total does not include certified facilities in US territories.


Source: Oscar Report 10. Facility Counts: Active Providers. Health Care Financing Administration, Center for Medicaid and State
Operations. December 2000.

National Pharmaceutical Council 3-7


Pharmaceutical Benefits 2000

Licensed Pharmacies (As of June 30, 2000)*


Non-Independent
Hospital/ Community Out-of-State or
Total Institutional Independent Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 73,781 8,502 25,273 15,046 7,714
Alabama 1,779 178 816 548 237
Alaska 111 (g) 12 (h) - - 122
Arizona 845 110 158 577 0
Arkansas 739 173 230 509 117
California 6,271 647 5,456 (a) - 168
Colorado 817 - - - 205
Connecticut 685 58 207 420 175
Delaware 154 13 19 128 216
District of Columbia 150 15 60 75 0
Florida 6,176 1,965 3,581 (a) (a) 272
Georgia 2,358 216 (p) (p) -
Hawaii 407 - - - 167
Idaho 486 57 250 (a, e) - 159
Illinois 2,788 358 2,429 (a) (a) 198
Indiana 1,353 197 - - 145
Iowa 1,188 131 (f) 825 (a, f) (a) 216
Kansas 787 178 609 (a) - 230
Kentucky 1,438 125 466 671 176
Louisiana 1,663 171 585 520 223
Maine 290 42 - - 187
Maryland 1,243 (i) 61 274 600 175
Massachusetts 1,189 (j) 158 345 669 0
Michigan 2,329 - - 31 -
Minnesota 1,338 181 516 461 200
Mississippi 962 130 - - 220
Missouri 1,550 (k) 135 - - 254
Montana 318 24 - - 111
Nebraska 464 95 - - 181 (l)
Nevada 575 43 187 345 172
New Hampshire 263 34 47 169 0
New Jersey 2,308 - - - -
New Mexico 541 56 128 (a) 152 (a) 182
New York 4,456 499 2,042 1,902 N/A
North Carolina 2,032 (f) 154 554 967 189
North Dakota 421 48 162 20 191
Ohio 2,833 (n) 228 574 1,574 234
Oklahoma 1,275 90 (d) 913 (a) (a) 257
Oregon 1,003 118 280 427 172
Pennsylvania 3,198 303 - - -
Rhode Island 206 22 48 138 210
South Carolina 1,079 136 285 566 215
South Dakota 421 41 146 75 159
Tennessee 1,710 370 493 727 120
Texas (a) 5,488 (b) 594 1,664 2,153 188
Utah 689 103 375 (a) (a) 157
Vermont 154 17 137 - 0
Virginia 1,513 - - - 307
Washington 1,440 216 (c) 412 628 184
West Virginia 797 - - - 217
Wisconsin 1,125 - - 0 0
Wyoming 348 - - - 206
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy.
Individual columns will not sum to total. Blanks (-) indicate that information was not available.
Source: 2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

3-8 National Pharmaceutical Council


Pharmaceutical Benefits 2000

LEGEND

a – Chains included in independent community pharmacies figure.


b – Also licenses 889 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacy.
c – Includes 107 hospital, 17 nursing home, 25 home infusion, six nuclear, 42 HMO, and 19 other pharmacies.
d – Approximately.
e – Plus 19 limited service and 53 parenteral admixture pharmacies.
f – In-state.
g – Includes eight wholesalers drug distributors.
h – Drug rooms.
i – Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV nuclear, research, and other.
j – Total also includes 12 home IV pharmacies, 11LTCF pharmacies, and one mail order pharmacy.
k – Includes 1,296 class A community/ambulatory pharmacies (no breakdown available between independent and chains
[4 or more]). Plus six long-term care, 26 home health, three nuclear, and one renal dialysis.
l – Nebraska “registers” out-of-state pharmacies.
m – Plus 336 who are practicing, but place is unknown.
n – Includes 223 nuclear, clinic, fluid therapy, mail order, specialty, and pharmacies serving nursing homes only.
o – As of January 7, 2000.
p – 2,142 (2,098 independent and chain pharmacies, 10 nuclear pharmacies, 28 prison pharmacies, four pharmacy clinics, and
two pharmacy school).

National Pharmaceutical Council 3-9


Pharmaceutical Benefits 2000

Physicians, 1998
Physicians Office Based Percent Primary Care Percent
State Physicians Per 1,000 Physicians Office Based Physicians Primary Care
National Total 696,600 2.6% 462,719 66.4% 249,291 35.8%
Alabama 8,816 2.1% 6,316 71.6% 3,335 37.8%
Alaska 1,185 1.8% 850 71.7% 439 37.0%
Arizona 9,821 2.0% 6,991 71.2% 3,393 34.5%
Arkansas 4,966 1.9% 3,615 72.8% 1,957 39.4%
California 82,640 2.5% 58,077 70.3% 29,432 35.6%
Colorado 9,734 2.5% 6,988 71.8% 3,523 36.2%
Connecticut 11,746 3.6% 7,387 62.9% 3,979 33.9%
Delaware 1,787 2.3% 1,216 68.0% 594 33.2%
District of Columbia 4,180 8.2% 1,990 47.6% 1,225 29.3%
Florida 36,573 2.5% 27,359 74.8% 12,327 33.7%
Georgia 16,821 2.2% 11,700 69.6% 6,122 36.4%
Hawaii 3,372 2.8% 2,385 70.7% 1,283 38.0%
Idaho 1,959 1.5% 1,619 82.6% 775 39.6%
Illinois 31,902 2.6% 20,107 63.0% 12,478 39.1%
Indiana 11,630 2.0% 8,429 72.5% 4,442 38.2%
Iowa 5,051 1.8% 3,499 69.3% 1,963 38.9%
Kansas 5,517 2.1% 3,817 69.2% 2,161 39.2%
Kentucky 8,381 2.2% 6,078 72.5% 3,137 37.4%
Louisiana 10,972 2.5% 7,295 66.5% 3,795 34.6%
Maine 2,831 2.2% 2,071 73.2% 1,097 38.7%
Maryland 20,925 4.1% 11,807 56.4% 6,400 30.6%
Massachusetts 25,729 4.2% 14,659 57.0% 7,956 30.9%
Michigan 22,229 2.2% 14,040 63.2% 8,296 37.3%
Minnesota 12,019 2.5% 8,058 67.0% 4,769 39.7%
Mississippi 4,710 1.7% 3,380 71.8% 1,744 37.0%
Missouri 12,801 2.4% 8,229 64.3% 4,303 33.6%
Montana 1,723 1.9% 1,442 83.7% 630 36.6%
Nebraska 3,692 2.2% 2,512 68.0% 1,501 40.7%
Nevada 3,115 1.7% 2,466 79.2% 1,141 36.6%
New Hampshire 2,860 2.3% 2,045 71.5% 1,058 37.0%
New Jersey 24,200 3.0% 15,954 65.9% 8,856 36.6%
New Mexico 3,911 2.1% 2,585 66.1% 1,435 36.7%
New York 71,186 3.9% 39,872 56.0% 24,934 35.0%
North Carolina 17,991 2.4% 12,157 67.6% 6,438 35.8%
North Dakota 1,456 2.3% 1,075 73.8% 603 41.4%
Ohio 26,822 2.4% 17,653 65.8% 10,017 37.3%
Oklahoma 5,841 1.8% 4,165 71.3% 2,158 36.9%
Oregon 7,585 2.3% 5,644 74.4% 2,832 37.3%
Pennsylvania 35,394 3.0% 22,502 63.6% 12,170 34.4%
Rhode Island 3,397 3.5% 2,050 60.3% 1,260 37.1%
South Carolina 8,196 2.1% 5,725 69.9% 3,086 37.7%
South Dakota 1,434 2.0% 1,105 77.1% 591 41.2%
Tennessee 13,728 2.5% 9,589 69.8% 4,946 36.0%
Texas 41,512 2.1% 28,526 68.7% 14,505 34.9%
Utah 4,297 2.0% 3,003 69.9% 1,535 35.7%
Vermont 1,837 3.1% 1,154 62.8% 746 40.6%
Virginia 17,298 2.6% 11,571 66.9% 6,253 36.1%
Washington 13,901 2.4% 9,923 71.4% 5,117 36.8%
West Virginia 4,029 2.3% 2,659 66.0% 1,551 38.5%
Wisconsin 12,037 2.3% 8,723 72.5% 4,622 38.4%
Wyoming 861 1.8% 657 76.3% 381 44.3%

Source: Area Resource File. Office of Research and Planning, Bureau of Health Professions. February 2000.

3-10 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Other Providers
Registered Nurses* Pharmacists** Pharmacists**
State Registered Nurses* per 1,000 (Licensed by State) per 1,000
National Total 2,161,700 8.1 334,851 1.2
Alabama 32,800 7.6 6,541 1.6
Alaska 6,300 10.3 518 0.8
Arizona 33,200 7.3 5,548 1.1
Arkansas 17,900 7.1 3,374 1.3
California 179,700 5.6 27,152 0.8
Colorado 30,900 7.9 5,254 1.3
Connecticut 33,400 10.2 4,265 1.3
Delaware 7,700 10.5 1,209 1.5
District of Columbia 8,900 16.8 1,350 2.6
Florida 119,300 8.1 19,425 1.3
Georgia 53,600 7.2 9,551 1.2
Hawaii 8,900 7.5 1,372 1.1
Idaho 7,100 5.9 1,447 1.1
Illinois 104,700 8.8 12,278 1.0
Indiana 46,900 8.0 8,038 1.4
Iowa 29,100 10.2 4,878 1.7
Kansas 21,600 8.3 3,540 1.4
Kentucky 30,400 7.8 4,746 1.2
Louisiana 32,400 7.4 5,774 1.3
Maine 13,300 10.7 1,267 1.0
Maryland 43,000 8.4 6,700 1.3
Massachusetts 73,300 12.0 9,283 1.5
Michigan 79,600 8.1 10,693 1.1
Minnesota 46,200 9.9 5,628 1.2
Mississippi 19,900 7.3 3,440 1.2
Missouri 51,200 9.5 6,317 1.2
Montana 7,100 8.1 1,262 1.4
Nebraska 15,200 9.2 2,445 1.4
Nevada 9,900 5.9 7,427 4.0
New Hampshire 11,200 9.6 1,824 1.5
New Jersey 67,100 8.3 15,542 1.9
New Mexico 11,700 6.8 2,258 1.2
New York 167,600 9.2 18,780 1.0
North Carolina 62,000 8.4 8,977 1.2
North Dakota 6,400 10.2 2,039 3.2
Ohio 101,200 9.1 13,797 1.2
Oklahoma 19,600 5.9 4,560 1.4
Oregon 26,500 8.2 3,952 1.2
Pennsylvania 126,300 10.5 16,894 1.4
Rhode Island 11,400 11.6 1,723 1.8
South Carolina 27,400 7.3 5,116 1.3
South Dakota 7,700 10.4 1,391 2.0
Tennessee 46,400 8.0 7,358 1.3
Texas 124,200 6.4 19,825 1.0
Utah 13,000 6.3 2,140 1.0
Vermont 5,300 9.0 793 1.3
Virginia 54,400 8.1 7,471 1.1
Washington 43,500 7.8 6,279 1.1
West Virginia 15,000 8.3 2,948 1.7
Wisconsin 45,600 8.8 5,837 1.1
Wyoming 4,200 8.8 1,001 2.1

*As of December 1996. ** As of June 30, 2000.


Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Division of Nursing, 1996.
2000-2001 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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Section 4:
Pharmacy Program
Characteristics

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THE MEDICAID PROGRAM


Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State funded program of national health
assistance that provides health care coverage to certain individuals and families with low-incomes and resources.
The 50 States, the District of Columbia, and the U.S. territories of Puerto Rico, Guam, Virgin Islands, American
Samoa, and Northern Mariana Islands each operate medical assistance programs according to state or territorial
rules and criteria that vary within a broad framework of federal guidelines.

MEDICAID RECIPIENTS

Every state, in order to receive federal funding under Title XIX, must provide Medicaid benefits to certain
“categorically needy” persons. Categorically needy individuals include those who meet the requirements for the
block grant Temporary Assistance for Needy Families (TANF) program (replaced the Aid to Families with
Dependent Children (AFDC) program); and, with a few exceptions, the aged, blind, and disabled who receive
Supplemental Security Income (SSI). Other groups that are categorically needy and thus automatically eligible
for Medicaid include:

• Children under age six whose family income is at or below 133% of the Federal poverty level (FPL),
• All children (under age 19) born after September 30, 1983 in families with incomes at or below the FPL,
• Pregnant women whose family income is below 133% of the FPL,
• Certain Medicare beneficiaries, and
• Recipients of adoption assistance and foster care under Title IV-E of the Social Security Act.
States may also provide Medicaid coverage to optional groups, or other “categorically needy” groups. Optional
coverage may be extended to certain aged, blind, or disabled persons who do not normally qualify for mandatory
coverage due to higher incomes, but who are below the FPL. Coverage may also be extended to pregnant women
and infants up to age one who are not covered under mandatory coverage, but whose income is also below the
federal poverty level.

In addition to the “categorically needy” that must be covered by Medicaid programs, there are other groups who
are “medically needy” who may be included in Medicaid at the option of each state. States may elect to provide
services to persons whose income levels are above the level to qualify for Medicaid but have medical expenses so
excessive as to offset their incomes.

Along with designating groups of people who must be covered by a state’s Medicaid plan and defining other
groups that may be covered at the discretion of the state, the federal government specifies certain general
requirements that must be met for Medicaid eligibility. A state can provide coverage for persons who do not meet
these requirements (i.e., the uninsured), but state and/or local funds must be used to support the medical expenses
of these individuals. A Medicaid agency that chooses to cover other optional groups must provide Medicaid to all
eligible individuals in that group.

MEDICAID SERVICES

The original Title XIX legislation listed several types of medical care as eligible for federal funding. Federal
regulations pertaining to Medicaid mandate that in order to receive federal matching funds, certain basic services
must be offered to all “categorically needy” individuals. These services include:

• Inpatient and outpatient hospital services;


• Physician services;

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• Medical and surgical dental services;


• Laboratory and X-ray services;
• Nursing facility services (for persons 21 years of age or older);
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21;
• Family planning services and supplies;
• Home health services for persons eligible for nursing facility services;
• Rural health clinic services and any other ambulatory services offered by a rural health clinic that are
otherwise covered under the State plan;
• Nurse-midwife services (to the extent authorized under State law);
• Pediatric and family nurse practitioners services; and
• Federally-qualified health center services and any other ambulatory services offered by a federally-
qualified health center that are otherwise covered under the State plan.
If a State chooses to include the “medically needy” population, the State plan must provide, as a minimum, the
following services:

• Prenatal care and delivery services for pregnant women;


• Ambulatory services to individuals under age 18 and individuals entitled to institutional services;
• Home health services to individuals entitled to nursing facility services; and
• If the State plan includes services either in institutions for mental diseases or in intermediate care facilities
for the mentally retarded (ICF/MRs), it must offer medically needy groups certain services provided to
the categorically needy.
States may also receive Federal funding if they elect to provide other optional services. The most commonly
covered optional services under the Medicaid program include:

• Clinic services;
• Intermediate care facilities for the mentally retarded (ICFs/MR);
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
• TB-related services for TB infected persons;
• Prosthetic devices; and
• Dental services.
States may provide home and community-based care waiver services to certain individuals who are eligible for
Medicaid. The services to be provided to these persons may include case management, personal care services,
respite care services, adult day health services, homemaker/home health aide, rehabilitation, and other services
requested by the State and approved by HCFA.

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CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services

Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of inpatients. The
facility is one maintained primarily for the care and treatment of patients with disorders other than mental
diseases. There are several general federal limitations on inpatient hospital services that apply to all states with
Medicaid programs (42 CFR 440.10):

• The facility must be licensed or formally approved as a hospital by an officially designated authority for
state standard setting;
• The facility must meet the requirements for participation in Medicare;
• The care and treatment of inpatients must be under the direction of a physician or dentist; and
• The facility must have in effect an approved utilization review plan, applicable to all Medicaid patients,
unless a waiver has been granted by the Secretary of Health and Human Services.
In addition to the federal limitations, each state may impose further limitations on inpatient hospital services.

Outpatient Hospital Services

Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services
provided to an outpatient. Three federal limitations are imposed on these services; though states are free to
specify other limits on outpatient hospital services and many have chosen to do so.

• The services must be provided under the direction of a physician or dentist;


• The facility must be licensed or formally approved as a hospital by an officially designated authority for
state standard setting; and
• The facility must meet the requirements for participation in Medicare.

Rural Health Clinic Services

Rural health clinic (RHC) services became mandatory for the categorically needy in July 1978. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a clinic can be
certified only if the state permits the delivery of primary care by an NP or PA. Services in certified clinics must
be provided and furnished by a physician or by a PA, NP, nurse-midwife, or other specialized nurse practitioner.
Services and supplies are furnished as an incident to professional services. Part-time or intermittent visiting nurse
care and related medical supplies are provided if the clinic is located in a Health Manpower Shortage Area, the
services are furnished by nurses employed by the clinic, and the services are furnished to a homebound recipient
under a written plan of treatment.

Other Laboratory and X-Ray Services

Other laboratory and X-ray services are professional and technical laboratory and radiological services. As
specified in 42 CFR 440.30 (a-c), federal requirements for Medicaid mandate that these services be:

• Ordered and provided by or under the direction of a physician or other licensed practitioner of the healing
arts within the scope of his or her practice, as defined by state law or ordered and billed by a physician but
provided by an independent laboratory;
• Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic;
and
• Provided by a laboratory that meets the requirements for participation in Medicare.

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• In addition, the states can place limitations on “other laboratory and X-ray services.”

Skilled Nursing Facility Services

Skilled nursing facility (SNF) services are provided to individuals age 21 or older. They do not include services
provided in institutions for mental diseases (42 CFR 440.40(a)). These services must be required on a daily basis
and provided in an inpatient facility. Federal regulations require that the services be:

• Provided by a facility or a distinct part of a facility that is certified to meet the requirements for
participation. These requirements include provider agreements, facility certification, and facility
standards; and
• Ordered by and under the direction of a physician.
The services include those provided by any facility located on an Indian reservation and certified by the Secretary
of Health and Human Services. Further, the requirements concerning control of the utilization of Medicaid
services affect skilled nursing facility services in areas such as certification and re-certification of need for
inpatient care, individual written plan of care, etc.

Early and Periodic Screening, Diagnosis and Treatment

Early and periodic screening, diagnosis and treatment (EPSDT) refers to screening and diagnostic services to
determine physical or mental defects in recipients under age 21, as well as health care, treatment and other
measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). Certain
basic screening and treatment services must be provided by each state as a minimum (42 CFR 441.56). These
services include:

• Health and developmental history screening;


• Unclothed physical examination;
• Developmental assessment;
• Immunizations appropriate for age and health history;
• Assessment of nutritional status;
• Vision testing;
• Hearing testing;
• Laboratory procedures appropriate for age and population group;
• Dental services furnished by direct referral to a dentist for diagnosis and treatment for children three years
of age and over;
• Treatment of defects in vision and hearing, including eyeglasses and hearing aids; and
• Dental care needed for relief of pain and infections, restoration of teeth and maintenance of dental health.
The state Medicaid agency may provide for any other medical or remedial care specified as a Medicaid service
even if the agency does not otherwise provide for these services to other recipients or provides for them in a lesser
amount, duration, or scope.

Family Planning Services

Family planning services and supplies are allowable for women of childbearing age as a means of enabling
individuals to freely determine the number and spacing of their children. Although there are no federal
regulations defining what family planning services a state can provide, provisional regulations define family
planning services as consultation (including counseling and patient education), examination, and treatment,

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furnished by or under the supervision of a physician or prescribed by a physician; laboratory examination;


medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception; natural
family planning methods, diagnosis and treatment for infertility; and voluntary sterilization. In addition, states
may provide any medically approved means other than abortion, for family planning purposes, if furnished by or
under supervision of a physician or if prescribed by a physician. Abortions are specifically excluded from family
planning services and states are prohibited from considering any abortion as a family planning service.

Voluntary sterilization must be included among the range of family planning services offered by a state. Federal
regulations require that the individual to be sterilized voluntarily give informed written consent and that the
individual must be mentally competent and at least 21 years of age at the time consent is obtained.

Physicians’ Services

Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a skilled nursing
facility, or elsewhere. Such services must be within the physicians’ scope of practice of medicine or osteopathy
as defined by state law, and by or under the personal supervision of an individual licensed under state law to
practice medicine or osteopathy.

Prescribed Drugs

Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the cure, mitigation,
or prevention of disease, or for health maintenance, which are prescribed by a physician or other licensed
practitioner of the healing arts within the scope of their professional practice, as defined and limited by Federal
and State law (42 CFR 440.120). The drugs must be dispensed by licensed authorized practitioners on a written
prescription that is recorded and maintained in the pharmacist’s or practitioner’s records.

Home Health Services

Home health services are provided to a recipient at his or her place of residence. This does not include a hospital,
skilled nursing facility, or intermediate care facility (ICF), except for home health services in an ICF that are not
required to be provided by the facility. Services provided must be on physicians’ orders as part of a written plan
of care that is reviewed by the physician every 62 days. Home health services include three mandatory services
(part-time nursing, home health aide, medical supplies and equipment) and four optional service (physical
therapy, occupational therapy, speech pathology, and audiology services) (42 CFR 440.70). These services are
defined as follows:

• Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a home health agency.
If there is no home health agency in the area, services may be provided by a registered nurse who is
currently licensed to practice in the state, receives written orders from the patient’s physician, documents
the care and services provided, and has had orientation to acceptable clinical and administrative record
keeping from a health department nurse.
• Home Health Aide: Home health aide services provided by a home health agency.
• Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are suitable for use in
the home.
• Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology Services: PT, OT,
speech and hearing services provided by a home health agency or a facility licensed by the State to
provide medical rehabilitation.
• Home health services are provided to categorically needy recipients age 21 and over and to those under
21 only if the state plan provides SNF services for them.

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Personal Support Services

Personal support services consist of a variety of services including personal care, targeted case management,
home and community-based care for functionally disabled elderly, rehabilitative services, hospice services, and
nurse midwife, nurse practitioner, and private duty nursing. Details of these services are provided below:

• Personal Care Services: Services provided to an individual who is not an inpatient or resident of a
hospital, nursing facility, immediate care facility for the mentally retarded, or institution for mental
disease. Services are authorized by a physician in accordance with treatment or service plan authorized
by the state, provided by a qualified individual who is not a member of the recipients family, and
furnished in a home or other location.
• Rehabilitative Services: These services include any medical or remedial service recommended by a
physician or other licensed practitioner of the healing arts within the scope of state law. Services are for
the maximum reduction of physical or mental disability and restoration of a recipient to their best possible
functional level.
• Hospice Services: Hospice services can be received in a hospice facility or elsewhere. Services are
provided to terminally ill individuals by an authorized hospice program under a written plan established
and reviewed by the attending physician, medical director or physician designee of the program, and an
interdisciplinary group.
• Nurse Midwife: Services that encompass the management and care of mothers and newborns. Care is
provided throughout the maternity cycle and is furnished within the scope of practice authorized by the
state.

Nurse-Midwife Services

Nurse-midwife services are those concerned with management of the care of mothers and newborns throughout
the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that payment be made providing
for nurse-midwife services to categorically needy recipients (42 CFR 440.165). These provisions require states to
provide coverage for nurse-midwife services to the extent that the nurse-midwife is authorized to practice under
state law or regulation. The statute also requires that states offer direct reimbursement to nurse-midwives as one
of the payment options. Nurse-midwives must be registered nurses who are either certified by an organization
recognized by the Secretary of HHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.

Pediatric Nurse Practitioner and Family Nurse Practitioner Services

The Omnibus Budget Reconciliation Act of 1989 provides for the availability and accessibility of services
furnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse practitioner (CFNP) to
Medicaid recipients. These provisions require that services be covered to the extent that the CPNPs or CFNPs are
authorized to practice under state law or regulation, regardless of whether they are supervised by or associated
with a physician or other health care provider. States are required to offer direct payment to CPNPs and CFNPs
as one of their payment options.

CPNP and CFNP certification requirements include a current license to practice as a registered nurse in the state,
meet the applicable state requirements for qualification of pediatric nurse practitioners or family nurse
practitioners, and be currently certified by the American Nurses’ Association as a pediatric nurse practitioner or a
family nurse practitioner.

Federally Qualified Health Center and other Ambulatory Services

Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other ambulatory services
offered by an FQHC under the provisions of the Omnibus Budget Reconciliation Act of 1989. The definition of

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FQHC services is the same as that of the services provided by rural health clinics (RHC). FQHC services include
physician services, services provided by physician assistants, nurse practitioners, clinical psychologists, clinical
social workers, and services and supplies incident to services normally covered if furnished by a physician or if
incident to a physician’s services.

FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant Health Centers,
and Health Care for the Homeless. These centers may qualify as providers of service under Medicaid, under the
following conditions:

• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service Act;
• The Health Resources and Services Administration recommends, and the HHS Secretary determines, that
the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements. Such a waiver
cannot exceed two years.

AMOUNT AND DURATION OF SERVICES

Within broad Federal guidelines and certain limitations, states may determine the amount and duration of services
offered under their Medicaid programs. Federal regulations require that the amount and/or duration of each type
of medical and remedial care and services furnished under a state’s program must be specified in the state plan,
and that these types of care and services must be sufficient in amount, duration, and scope to “reasonably achieve”
their purpose. States are required to provide Medicaid coverage for comparable amounts, duration, and scope of
service to all “categorically needy” and categorically-related eligible person.

Each state plan must include a description of the methods that will be used to assure that the medical and remedial
care and services delivered are of high quality, as well as a description of the standards established by the state to
assure high quality care. The regulations also require that the fee structures developed must result in participation
of a sufficient number of providers so that eligible persons can receive the medical care and services included in
the plan, at least to the extent that these are available to the general population. The law further requires that
services provided under the plan be available throughout the state. Recipients are to have freedom of choice with
regard to where they receive their care, including an option to obtain their care through organizations that provide
services or arrange for their availability on a prepayment basis, such as health maintenance organizations.

MEDICAID PAYMENT FOR SERVICES

In 1998, the Medicaid program provided health care services to 40.6 million people, at a cost of $142 billion. The
Medicaid program operates on the basis of a division of responsibilities between the federal government and the
states with the federal government paying states for a portion of state medical expenditures and administrative
costs. Funding for the program is shared between the two bodies, with the federal government matching state
health care provider reimbursements at an authorized rate of between 50% and 83%, depending on the state’s per
capita income (see the Federal Medical Assistance Percentage (FMAP) table, page 4-12).

The FMAP is based upon the state’s per capita income; if a state’s per capita income is equal to or greater than the
national average, the federal share is 50%. If a state’s per capita income is below the national average, the federal
share is increased up to a maximum of 83%.

The percentages apply to state expenditures for assistance payments and medical services. Federal statute
provides separate federal matching amounts for administrative costs. Cost sharing for administrative expenditures
vary with the services, i.e., 75% for training, 90% for designing, developing or installing mechanized claims
processing and information retrieval, etc. (Federal Medicaid Law (Section 1903(a)(2) et seq.)).

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Total U.S. Medical Assistance Recipients*


by Type of Service

Percent Percent Percent


Service FY 1998 Using Service FY 1997 Using Service Change
Pharmaceuticals 19,337,543 47.6% 20,954,163 62.4% -7.7%

Physicians 18,554,746 45.6% 21,170,194 63.0% -12.4%

Hospital Outpatient 12,157,729 29.9% 13,632,035 40.6% -10.8%

Lab/X-ray 9,380,689 23.1% 11,074,000 33.0% -15.3%


EPSDT 6,174,628 15.2% 6,449,748 19.2% -4.3%

Clinic 5,285,415 13.0% 4,713,424 14.0% +12.1%

Dental 4,965,202 12.2% 5,935,344 17.7% -16.3%

Hospital Inpatient 4,408,162 10.8% 4,834,677 14.4% -8.8%

Other Practitioners 4,341,915 10.7% 5,141,685 15.3% -15.6%

Personal Support Services* 3,108,432 7.6% -- -- --

Family Planning 2,011,124 4.9% 2,091,116 6.2% -3.8%

Nursing Facility/Services 1,645,728 4.0% 1,603,018 4.8% +2.7%

Home Health Care 1,224,714 3.0% 1,861,124 5.5% -34.2%

ICF-Mentally Retarded 126,490 0.3% 136,025 0.4% -7.0%

Total Recipients 40,649,482‡ 33,579,168‡ +21.1%

*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal Support Services, please refer to page 4-8 for an explanation of these services.
‡Figures will not add to totals due to recipients’ use of multiple services.

Source: HCFA, CMSO, HCFA-2082 Report, FY98.

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Total U.S. Medical Assistance Payments*


by Type of Service

Percent Percent Percent


Service FY 1998 of Total FY 1997 of Total Change
Nursing Facility/Services $31,892,064,551 22.4% $30,503,842,614 24.7% +4.6%

Hospital Inpatient $24,299,261,217 17.1% $25,152,622,821 20.4% -3.4%

Pharmaceuticals $13,521,707,689 9.5% $11,972,331,192 9.7% +12.9%

ICF-Mentally Retarded $9,481,723,907 6.7% $9,798,302,785 7.9% -3.2%


Personal Support Services* $8,221,956,899 5.8% -- -- --

Physicians $6,070,022,680 4.3% $7,041,038,648 5.7% -13.8%

Hospital Outpatient $5,758,982,745 4.0% $6,168,996,402 5.0% -6.6%

Clinic $3,921,167,731 2.8% $4,252,480,130 3.4% -7.8%

Home Health Care $2,701,512,000 1.9% $12,236,599,938 9.9% -77.9%

EPSDT $1,334,828,107 0.9% $1,616,718,462 1.3% -17.4%

Lab/X-ray $938,700,266 0.7% $1,032,714,257 0.8% -9.1%

Dental $901,385,043 0.6% $979,220,296 0.8% -7.9%

Other Practitioners $587,137,593 0.4% $1,035,781,863 0.8% -43.3%

Family Planning $449,136,397 0.3% $418,365,295 0.3% +7.4%

Total Payments $142,317,903,795‡ $123,552,098,563‡ +15.2%

*Many services originally recognized as Home Health Care, Physicians, Other Practitioners and other services are now reported as
Personal Support Services, please refer to page 4-8 for an explanation of these services.
‡Figures may not add to totals due to rounding.

Source: HCFA, CMSO, HCFA-2082 Report, FY98.

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Federal Medical Assistance Percentage (FMAP), FY1999 and FY2000


State 1999 FMAP 2000 FMAP 2000 Enhanced FMAP*
Alabama 69.27% 69.57% 78.70%
Alaska** 59.80% 59.80% 71.86%
Arizona 65.50% 65.92% 76.14%
Arkansas 72.96% 72.85% 80.99%
California 51.55% 51.67% 66.17%
Colorado 50.59% 50.00% 65.00%
Connecticut 50.00% 50.00% 65.00%
Delaware 50.00% 50.00% 65.00%
District of Columbia** 70.00% 70.00% 79.00%
Florida 55.82% 56.52% 69.57%
Georgia 60.47% 59.88% 71.91%
Hawaii 50.00% 51.01% 65.71%
Idaho 69.85% 70.15% 79.11%
Illinois 50.00% 50.00% 65.00%
Indiana 61.01% 61.74% 73.22%
Iowa 63.32% 63.06% 74.14%
Kansas 60.05% 60.03% 72.02%
Kentucky 70.53% 70.55% 79.38%
Louisiana 70.37% 70.32% 79.22%
Maine 66.40% 66.22% 76.36%
Maryland 50.00% 50.00% 65.00%
Massachusetts 50.00% 50.00% 65.00%
Michigan 52.72% 55.11% 68.58%
Minnesota 51.50% 51.48% 66.04%
Mississippi 76.78% 76.80% 83.76%
Missouri 60.24% 60.51% 72.36%
Montana 71.73% 72.30% 80.61%
Nebraska 61.46% 60.88% 72.62%
Nevada 50.00% 50.00% 65.00%
New Hampshire 50.00% 50.00% 65.00%
New Jersey 50.00% 50.00% 65.00%
New Mexico 72.98% 73.32% 81.32%
New York 50.00% 50.00% 65.00%
North Carolina 63.07% 62.49% 73.74%
North Dakota 69.94% 70.42% 79.29%
Ohio 58.26% 58.67% 71.07%
Oklahoma 70.84% 71.09% 79.76%
Oregon 60.55% 59.96% 71.97%
Pennsylvania 53.77% 53.82% 67.67%
Rhode Island 54.05% 53.77% 67.64%
South Carolina 69.85% 69.95% 78.96%
South Dakota 68.16% 68.72% 78.11%
Tennessee 63.09% 63.10% 74.17%
Texas 62.45% 61.36% 72.95%
Utah 71.78% 71.55% 80.08%
Vermont 61.97% 62.24% 73.57%
Virginia 51.60% 51.67% 66.17%
Washington 52.50% 51.83% 66.28%
West Virginia 74.47% 74.78% 82.35%
Wisconsin 58.85% 58.78% 71.15%
Wyoming 64.08% 64.04% 74.83%

* The "Enhanced Federal Medical Assistance Percentages" are for use in the new Children's Health Insurance Program under Title
XXI, and for some or all of children's medical assistance under the new Medicaid sections 1905(u)(2) and 1905(u)(3).
** For 1999 and 2000, the values in the table were set for state plans under Titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is
54.13% and for the District of Columbia is 50.00%.
Source: Federal Register, January 12, 1999, Vol. 64, No. 7, pages 1805-1808.

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Medicaid Payments and Recipients, 1998


Total Total Payments
State Vendor Payments Recipients Per Recipient
National Total $142,317,903,795 40,649,482 $3,501
Alabama $1,902,300,047 527,078 $3,609
Alaska $330,378,398 74,508 $4,434
Arizona $1,643,966,305 507,668 $3,238
Arkansas $1,375,797,421 424,727 $3,239
California $14,236,592,915 7,082,175 $2,010
Colorado $1,439,366,499 344,916 $4,173
Connecticut $2,420,791,474 381,208 $6,350
Delaware $419,732,143 101,436 $4,138
District of Columbia $731,292,552 166,146 $4,402
Florida $5,686,844,862 1,904,591 $2,986
Georgia $3,012,346,312 1,221,978 $2,465
Hawaii $507,433,146 184,614 $2,749
Idaho $424,512,387 123,176 $3,446
Illinois $6,172,865,261 1,363,856 $4,526
Indiana $2,564,005,047 607,293 $4,222
Iowa $1,288,770,390 314,936 $4,092
Kansas $916,323,608 241,933 $3,788
Kentucky $2,425,288,141 644,482 $3,763
Louisiana $2,383,508,985 720,615 $3,308
Maine $747,027,618 170,456 $4,383
Maryland $2,489,280,148 561,085 $4,437
Massachusetts $4,609,360,933 908,238 $5,075
Michigan $4,345,007,824 1,362,890 $3,188
Minnesota $2,924,447,719 538,413 $5,432
Mississippi $1,442,373,276 485,767 $2,969
Missouri $2,569,646,129 734,015 $3,501
Montana $361,238,668 100,760 $3,585
Nebraska $753,162,904 211,188 $3,566
Nevada $462,087,777 128,144 $3,606
New Hampshire $606,004,232 93,970 $6,449
New Jersey $4,218,822,993 813,251 $5,188
New Mexico $862,144,872 329,418 $2,617
New York $24,298,610,635 3,073,241 $7,907
North Carolina $4,013,996,742 1,167,988 $3,437
North Dakota $341,015,420 62,280 $5,476
Ohio $6,120,967,557 1,290,776 $4,742
Oklahoma $1,177,853,941 342,475 $3,439
Oregon $1,377,514,740 511,171 $2,695
Pennsylvania $6,080,191,710 1,523,120 $3,992
Puerto Rico $250,000,000 964,015 $259
Rhode Island $919,353,410 153,130 $6,004
South Carolina $2,018,620,428 594,962 $3,393
South Dakota $355,833,902 89,537 $3,974
Tennessee $3,167,188,993 1,843,661 $1,718
Texas $7,139,928,843 2,324,810 $3,071
Utah $618,675,433 215,801 $2,867
Vermont $351,341,290 123,992 $2,834
Virgin Islands $10,097,973 19,764 $511
Virginia $2,118,202,866 653,236 $3,243
Washington $2,044,234,831 1,413,208 $1,447
West Virginia $1,243,150,526 342,668 $3,628
Wisconsin $2,206,398,750 518,595 $4,255
Wyoming $192,004,819 46,121 $4,163
Source: HCFA, CMSO, HCFA-2082 Report, FY98.

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Pharmaceutical Benefits 2000

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Pharmaceutical Benefits 2000

MEDICAID DRUG PROGRAM


The Medicaid program defines prescribed drugs as simple or compound substances or mixtures of substances
prescribed for the cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional practice (42 CFR
440.120). The drugs must be dispensed by licensed authorized practitioners on a written prescription that is
recorded and maintained in the pharmacist’s or practitioner’s records.

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

On July 31, 1987, the Health Care Financing Administration (HCFA) published a notice of the final rule for limits
on payments for drugs in the Medicaid program. The regulations adopted in the rule became effective October
29, 1987 (52 FR 28648). In this final rule, HCFA attempted to (1) respond to public comments on the NPRM (51
FR 2956); (2) provide maximum flexibility to the states in their administration of the Medicaid program; (3)
provide responsible but not burdensome federal oversight of the Medicaid program; and (4) take advantage of
savings in the marketplace for multiple-source drugs.

To accomplish this, HCFA adopted a federal upper limit standard for certain multiple-source drugs, based on
application of a specific formula. The upper limit for other drugs is similar, in that it retains the estimated
acquisition cost (EAC) as the upper limit standard that state agencies must meet. However, this standard is
applied on an aggregate basis rather than on a prescription-specific basis. State agencies are therefore encouraged
to exercise maximum flexibility in establishing their own payment methods (see the Federal Register, Vol. 52,
No. 147, Friday, July 31, 1987, page 28648).

Multiple-Source Drugs

A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a drug
marketed or sold by the same manufacturer or labeler under two or more different proprietary names or under a
proprietary name and without such a name.

A specific upper limit for a multiple-source drug may be established if the following requirements are met:

• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been
evaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Products
with Therapeutically Equivalent Evaluations, and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its publication) in
the current editions of published compendia of cost information for drugs available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply if a
physician certifies in his or her own handwriting that a specific brand is “medically necessary” for a particular
recipient.

The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary” must appear
on the face of the prescription. The rule specifically states that a check-off box on a prescription form is not
acceptable, but it does not address the use of two-line prescription forms.

The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source drugs will
be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in quantities of 100
tablets or capsules (or if the drug is not commonly available in quantities of 100, the package size commonly
listed), or in the case of liquids, the commonly listed size, plus a reasonable dispensing fee.

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Pharmaceutical Benefits 2000

Other Drugs

A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the physician,
(2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug. Payments for these drugs
must not exceed, in the aggregate, payment levels determined by applying the lower of:

• Estimated acquisition cost (EAC) plus reasonable dispensing fees; or


• The provider’s usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method, as long as their aggregate
expenditures do not exceed what would have been paid under EAC principles.

Other Requirements

The rule requires states to submit a state plan that describes their payment methods for prescribed drugs. The rule
does not prescribe a preferred payment method, as long as the state’s aggregate spending in each category is equal
to or below the upper limit requirements. States are also required to submit assurances to HCFA that the
requirements are met.

The rule does not prescribe a preferred payment method for the states, but gives states the flexibility to determine
how they will pay for prescription drugs under Medicaid. As long as the state’s aggregate spending is at or below
the amount derived from the formula, the state is free to maintain its current payment program or adopt other
methods. States can alter payment rates for individual drugs, balancing payment increases for certain products
with payment decreases for other drugs so that, in the aggregate, the program does not exceed the established
limit. With the establishment of upper limit payment maximums, some states may alter their current payment
methods to comply with the established limits.

State programs vary, depending upon whether or not state maximum allowable cost programs cover the same
drugs listed by HCFA. States with established MAC programs may be unaffected if their MAC rates are already
low, or they may have to make certain adjustments in their MAC levels to meet the federal aggregate expenditure
limits. States without MAC programs may develop a new payment method to increase the use of lower cost
generic drug products in order to stay within the upper payment limits, or may simply adopt HCFA’s formula for
listed drug products.

DRUG RECIPIENTS

Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. Today,
all 50 States and the District of Columbia cover drugs under the Medicaid program.

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Pharmaceutical Benefits 2000

Drug Payments and Recipients, 1998


Total Total Drug Payments
State Drug Payments Drug Recipients‡ Per Recipient
National Total* $13,521,707,689 19,337,543 $699
Alabama $236,674,147 395,290 $599
Alaska $32,887,828 43,734 $752
Arizona $1,442,917 56,796 $25
Arkansas $150,891,615 262,907 $574
California $1,553,598,462 2,644,430 $587
Colorado $110,159,725 147,033 $749
Connecticut $186,593,992 108,331 $1,722
Delaware $41,350,537 69,027 $599
District of Columbia $41,254,973 57,733 $715
Florida $933,782,041 1,014,372 $921
Georgia $370,562,935 805,923 $460
Hawaii $39,623,380 32,222 $1,230
Idaho $54,971,097 86,775 $633
Illinois $583,239,675 959,472 $608
Indiana $325,712,348 323,811 $1,006
Iowa $147,115,884 215,173 $684
Kansas $118,825,316 155,875 $762
Kentucky $319,983,951 429,102 $746
Louisiana $352,784,785 552,481 $639
Maine $121,771,298 137,816 $884
Maryland $148,532,940 176,403 $842
Massachusetts $497,146,531 613,186 $811
Michigan $374,145,567 589,818 $634
Minnesota $173,602,492 203,220 $854
Mississippi $231,735,360 368,609 $629
Missouri $382,512,566 353,902 $1,081
Montana $42,368,399 58,641 $723
Nebraska $92,558,539 145,408 $637
Nevada $34,518,901 50,903 $678
New Hampshire $55,374,478 70,339 $787
New Jersey $426,075,488 309,849 $1,375
New Mexico $41,507,229 96,637 $430
New York $1,368,451,273 1,803,428 $759
North Carolina $466,528,812 764,886 $610
North Dakota $27,619,684 37,675 $733
Ohio $645,118,962 702,143 $919
Oklahoma - - -
Oregon $87,805,350 148,258 $592
Pennsylvania $525,261,211 580,749 $904
Rhode Island $61,401,958 44,852 $1,369
South Carolina $224,962,203 401,611 $560
South Dakota $31,106,511 46,588 $668
Tennessee $36 1 $36
Texas $817,591,112 1,894,447 $432
Utah $68,827,853 126,953 $542
Vermont $43,445,887 58,037 $749
Virginia $284,578,558 383,880 $741
Washington $244,478,658 274,463 $891
West Virginia $148,962,081 267,398 $557
Wisconsin $232,326,359 221,508 $1,049
Wyoming $17,138,952 32,510 $527
*National figures include Puerto Rico and the Virgin Islands.
**Oklahoma did not submit detailed drug information for 1998.
‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
Source: HCFA, CMSO, HCFA-2082 Report, FY98.

National Pharmaceutical Council 4-17


Pharmaceutical Benefits 2000

Drug Payment Trends


State 1994 1995 1996 1997 1998
National Total* $8,873,950,031 $9,790,651,449 $10,697,438,066 $11,972,331,192 $13,521,707,689
Alabama $163,021,321 $178,667,753 $203,811,076 $226,105,163 $236,674,147
Alaska $16,744,047 $18,469,364 $21,661,213 $28,376,842 $32,887,828
Arizona $1,165,786 $2,027,734 $2,460,613 $1,855,672 $1,442,917
Arkansas $88,069,017 $102,114,998 $115,070,827 $135,757,334 $150,891,615
California $1,122,754,027 $1,145,514,700 $1,223,444,736 $1,335,065,753 $1,553,598,462
Colorado $70,483,595 $78,833,103 $82,543,502 $96,964,178 $110,159,725
Connecticut $120,470,177 $145,366,245 $146,856,083 $166,667,301 $186,593,992
Delaware $18,351,293 $21,458,681 $27,743,076 $34,713,581 $41,350,537
District of Columbia $25,227,269 $26,231,966 $32,765,197 $37,512,355 $41,254,973
Florida $484,052,934 $556,864,923 $658,291,958 $772,780,639 $933,782,041
Georgia $260,307,087 $288,511,672 $319,230,386 $339,257,021 $370,562,935
Hawaii** $34,461,968 $24,802,573 $26,854,246 - $39,623,380
Idaho $29,378,146 $33,153,237 $41,028,033 $45,042,165 $54,971,097
Illinois $330,697,673 $440,883,001 $446,214,047 $523,561,885 $583,239,675
Indiana $232,645,959 $187,674,037 $269,001,714 $293,318,000 $325,712,348
Iowa $91,202,410 $97,382,501 $111,346,007 $123,861,339 $147,115,884
Kansas $71,285,408 $81,455,408 $90,754,656 $104,628,978 $118,825,316
Kentucky $217,044,606 $251,745,610 $272,539,525 $316,464,180 $319,983,951
Louisiana $269,035,462 $292,293,619 $297,433,210 $315,444,016 $352,784,785
Maine $64,043,624 $63,906,058 $83,822,289 $102,537,196 $121,771,298
Maryland $125,216,705 $139,205,331 $154,908,882 $172,701,280 $148,532,940
Massachusetts $251,184,700 $308,411,398 $302,911,947 $398,076,057 $497,146,531
Michigan $290,264,217 $312,003,749 $352,620,438 $365,282,227 $374,145,567
Minnesota $113,841,194 $148,450,414 $150,350,355 $155,830,086 $173,602,492
Mississippi $140,045,378 $162,743,883 $176,758,960 $208,577,199 $231,735,360
Missouri $228,660,484 $259,657,651 $281,700,005 $320,660,206 $382,512,566
Montana $26,211,646 $28,335,142 $32,742,122 $35,470,912 $42,368,399
Nebraska $55,495,790 $61,738,837 $71,482,836 $79,727,194 $92,558,539
Nevada $17,653,922 $21,320,507 $24,384,747 $26,652,299 $34,518,901
New Hampshire $28,419,726 $34,099,265 $42,310,704 $45,361,780 $55,374,478
New Jersey $308,046,437 $344,176,481 $374,015,636 $369,839,049 $426,075,488
New Mexico $47,770,092 $50,545,800 $61,171,361 $63,345,896 $41,507,229
New York $727,303,151 $819,359,316 $907,083,895 $1,090,917,486 $1,368,451,273
North Carolina $215,197,252 $277,430,790 $344,950,165 $403,811,339 $466,528,812
North Dakota $17,639,044 $19,711,865 $20,904,298 $25,226,544 $27,619,684
Ohio $415,250,727 $480,233,424 $518,641,009 $580,572,988 $645,118,962
Oklahoma** $89,253,227 $100,909,395 $98,292,786 $110,880,182 -
Oregon $85,902,712 $82,647,757 $67,013,699 $73,216,753 $87,805,350
Pennsylvania $489,131,313 $543,774,387 $536,797,657 $552,268,949 $525,261,211
Rhode Island $39,752,373 $47,808,612 $45,679,642 $52,165,739 $61,401,958
South Carolina $110,845,482 $124,500,348 $143,804,519 $159,606,414 $224,962,203
South Dakota $19,017,682 $21,567,935 $24,147,295 $27,591,466 $31,106,511
Tennessee $76,314,794 $190,467 $15,337 $1,118 $36
Texas $511,841,929 $578,661,512 $667,743,192 $750,056,208 $817,591,112
Utah $39,728,466 $44,397,971 $48,149,414 $50,825,675 $68,827,853
Vermont $28,384,265 $33,658,620 $36,539,101 $44,291,004 $43,445,887
Virginia $195,777,613 $213,182,924 $221,421,619 $249,620,903 $284,578,558
Washington $168,193,537 $161,555,588 $172,652,369 $204,980,369 $244,478,658
West Virginia $106,852,366 $130,451,359 $124,984,023 $133,044,683 $148,962,081
Wisconsin $183,836,535 $190,678,825 $205,429,565 $205,503,614 $232,326,359
Wyoming $10,475,463 $11,884,713 $13,635,463 $14,864,016 $17,138,952

*National figures include Puerto Rico and the Virgin Islands.


**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY98.

4-18 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Drug Payment - Percent Change from 1997 to 1998


State 1997 1998 Percent Change
National Total* $11,972,331,192 $13,521,707,689 13%
Alabama $226,105,163 $236,674,147 5%
Alaska $28,376,842 $32,887,828 16%
Arizona $1,855,672 $1,442,917 -22%
Arkansas $135,757,334 $150,891,615 11%
California $1,335,065,753 $1,553,598,462 16%
Colorado $96,964,178 $110,159,725 14%
Connecticut $166,667,301 $186,593,992 12%
Delaware $34,713,581 $41,350,537 19%
District of Columbia $37,512,355 $41,254,973 10%
Florida $772,780,639 $933,782,041 21%
Georgia $339,257,021 $370,562,935 9%
Hawaii** - $39,623,380 -
Idaho $45,042,165 $54,971,097 22%
Illinois $523,561,885 $583,239,675 11%
Indiana $293,318,000 $325,712,348 11%
Iowa $123,861,339 $147,115,884 19%
Kansas $104,628,978 $118,825,316 14%
Kentucky $316,464,180 $319,983,951 1%
Louisiana $315,444,016 $352,784,785 12%
Maine $102,537,196 $121,771,298 19%
Maryland $172,701,280 $148,532,940 -14%
Massachusetts $398,076,057 $497,146,531 25%
Michigan $365,282,227 $374,145,567 2%
Minnesota $155,830,086 $173,602,492 11%
Mississippi $208,577,199 $231,735,360 11%
Missouri $320,660,206 $382,512,566 19%
Montana $35,470,912 $42,368,399 19%
Nebraska $79,727,194 $92,558,539 16%
Nevada $26,652,299 $34,518,901 30%
New Hampshire $45,361,780 $55,374,478 22%
New Jersey $369,839,049 $426,075,488 15%
New Mexico $63,345,896 $41,507,229 -34%
New York $1,090,917,486 $1,368,451,273 25%
North Carolina $403,811,339 $466,528,812 16%
North Dakota $25,226,544 $27,619,684 9%
Ohio $580,572,988 $645,118,962 11%
Oklahoma** $110,880,182 - -
Oregon $73,216,753 $87,805,350 20%
Pennsylvania $552,268,949 $525,261,211 -5%
Rhode Island $52,165,739 $61,401,958 18%
South Carolina $159,606,414 $224,962,203 41%
South Dakota $27,591,466 $31,106,511 13%
Tennessee $1,118 $36 -97%
Texas $750,056,208 $817,591,112 9%
Utah $50,825,675 $68,827,853 35%
Vermont $44,291,004 $43,445,887 -2%
Virginia $249,620,903 $284,578,558 14%
Washington $204,980,369 $244,478,658 19%
West Virginia $133,044,683 $148,962,081 12%
Wisconsin $205,503,614 $232,326,359 13%
Wyoming $14,864,016 $17,138,952 15%

*National figures include Puerto Rico and the Virgin Islands.


**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

National Pharmaceutical Council 4-19


Pharmaceutical Benefits 2000

Ranking Based on Drug Payments


% of 1998 Total
1998 1998 Medicaid Drug 1997 1997
State Payments Ranking Payments Payments Ranking
California $1,553,598,462 1 11.49% $1,335,065,753 1
New York $1,368,451,273 2 10.12% $1,090,917,486 2
Florida $933,782,041 3 6.91% $772,780,639 3
Texas $817,591,112 4 6.05% $750,056,208 4
Ohio $645,118,962 5 4.77% $580,572,988 5
Illinois $583,239,675 6 4.31% $523,561,885 7
Pennsylvania $525,261,211 7 3.88% $552,268,949 6
Massachusetts $497,146,531 8 3.68% $398,076,057 9
North Carolina $466,528,812 9 3.45% $403,811,339 8
New Jersey $426,075,488 10 3.15% $369,839,049 10
Missouri $382,512,566 11 2.83% $320,660,206 13
Michigan $374,145,567 12 2.77% $365,282,227 11
Georgia $370,562,935 13 2.74% $339,257,021 12
Louisiana $352,784,785 14 2.61% $315,444,016 15
Indiana $325,712,348 15 2.41% $293,318,000 16
Kentucky $319,983,951 16 2.37% $316,464,180 14
Virginia $284,578,558 17 2.10% $249,620,903 17
Washington $244,478,658 18 1.81% $204,980,369 21
Alabama $236,674,147 19 1.75% $226,105,163 18
Wisconsin $232,326,359 20 1.72% $205,503,614 20
Mississippi $231,735,360 21 1.71% $208,577,199 19
South Carolina $224,962,203 22 1.66% $159,606,414 24
Connecticut $186,593,992 23 1.38% $166,667,301 23
Minnesota $173,602,492 24 1.28% $155,830,086 25
Arkansas $150,891,615 25 1.12% $135,757,334 26
West Virginia $148,962,081 26 1.10% $133,044,683 27
Maryland $148,532,940 27 1.10% $172,701,280 22
Iowa $147,115,884 28 1.09% $123,861,339 28
Maine $121,771,298 29 0.90% $102,537,196 31
Kansas $118,825,316 30 0.88% $104,628,978 30
Colorado $110,159,725 31 0.81% $96,964,178 32
Nebraska $92,558,539 32 0.68% $79,727,194 33
Oregon $87,805,350 33 0.65% $73,216,753 34
Utah $68,827,853 34 0.51% $50,825,675 37
Rhode Island $61,401,958 35 0.45% $52,165,739 36
New Hampshire $55,374,478 36 0.41% $45,361,780 38
Idaho $54,971,097 37 0.41% $45,042,165 39
Vermont $43,445,887 38 0.32% $44,291,004 40
Montana $42,368,399 39 0.31% $35,470,912 42
New Mexico $41,507,229 40 0.31% $63,345,896 35
Delaware $41,350,537 41 0.31% $34,713,581 43
District of Columbia $41,254,973 42 0.31% $37,512,355 41
Hawaii* $39,623,380 43 0.29% - -
Nevada $34,518,901 44 0.26% $26,652,299 46
Alaska $32,887,828 45 0.24% $28,376,842 44
South Dakota $31,106,511 46 0.23% $27,591,466 45
North Dakota $27,619,684 47 0.20% $25,226,544 47
Wyoming $17,138,952 48 0.13% $14,864,016 48
Arizona $1,442,917 49 0.01% $1,855,672 49
Tennessee $36 50 0.00% $1,118 50
Oklahoma* - - - $110,880,182 29

*Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY97, FY98.

4-20 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Drugs as a Percentage of Total Vendor Payments, 1998


Total Total % of Total
State Drug Payments Vendor Payments Vendor Payments
National Total* $13,521,707,689 $142,317,903,795 9.5%
Alabama $236,674,147 $1,902,300,047 12.4%
Alaska $32,887,828 $330,378,398 10.0%
Arizona $1,442,917 $1,643,966,305 0.1%
Arkansas $150,891,615 $1,375,797,421 11.0%
California $1,553,598,462 $14,236,592,915 10.9%
Colorado $110,159,725 $1,439,366,499 7.7%
Connecticut $186,593,992 $2,420,791,474 7.7%
Delaware $41,350,537 $419,732,143 9.9%
District of Columbia $41,254,973 $731,292,552 5.6%
Florida $933,782,041 $5,686,844,862 16.4%
Georgia $370,562,935 $3,012,346,312 12.3%
Hawaii $39,623,380 $507,433,146 7.8%
Idaho $54,971,097 $424,512,387 12.9%
Illinois $583,239,675 $6,172,865,261 9.4%
Indiana $325,712,348 $2,564,005,047 12.7%
Iowa $147,115,884 $1,288,770,390 11.4%
Kansas $118,825,316 $916,323,608 13.0%
Kentucky $319,983,951 $2,425,288,141 13.2%
Louisiana $352,784,785 $2,383,508,985 14.8%
Maine $121,771,298 $747,027,618 16.3%
Maryland $148,532,940 $2,489,280,148 6.0%
Massachusetts $497,146,531 $4,609,360,933 10.8%
Michigan $374,145,567 $4,345,007,824 8.6%
Minnesota $173,602,492 $2,924,447,719 5.9%
Mississippi $231,735,360 $1,442,373,276 16.1%
Missouri $382,512,566 $2,569,646,129 14.9%
Montana $42,368,399 $361,238,668 11.7%
Nebraska $92,558,539 $753,162,904 12.3%
Nevada $34,518,901 $462,087,777 7.5%
New Hampshire $55,374,478 $606,004,232 9.1%
New Jersey $426,075,488 $4,218,822,993 10.1%
New Mexico $41,507,229 $862,144,872 4.8%
New York $1,368,451,273 $24,298,610,635 5.6%
North Carolina $466,528,812 $4,013,996,742 11.6%
North Dakota $27,619,684 $341,015,420 8.1%
Ohio $645,118,962 $6,120,967,557 10.5%
Oklahoma** - $1,177,853,941 -
Oregon $87,805,350 $1,377,514,740 6.4%
Pennsylvania $525,261,211 $6,080,191,710 8.6%
Rhode Island $61,401,958 $919,353,410 6.7%
South Carolina $224,962,203 $2,018,620,428 11.1%
South Dakota $31,106,511 $355,833,902 8.7%
Tennessee $36 $3,167,188,993 0.0%
Texas $817,591,112 $7,139,928,843 11.5%
Utah $68,827,853 $618,675,433 11.1%
Vermont $43,445,887 $351,341,290 12.4%
Virginia $284,578,558 $2,118,202,866 13.4%
Washington $244,478,658 $2,044,234,831 12.0%
West Virginia $148,962,081 $1,243,150,526 12.0%
Wisconsin $232,326,359 $2,206,398,750 10.5%
Wyoming $17,138,952 $192,004,819 8.9%

*National figures include Puerto Rico and the Virgin Islands.


**Oklahoma did not submit detail drug information for 1998.
Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY98

National Pharmaceutical Council 4-21


Pharmaceutical Benefits 2000

Drugs as a Percentage of Total Vendor Payments, Trend


State 1994 1995 1996 1997 1998
National* 8.2% 8.1% 8.8% 9.7% 9.5%
Alabama 12.4% 12.3% 13.9% 14.4% 12.4%
Alaska 6.9% 7.3% 7.8% 8.8% 10.0%
Arizona 0.6% 0.9% 1.2% 0.8% 0.1%
Arkansas 7.0% 7.4% 9.4% 10.4% 11.0%
California 11.2% 10.9% 11.0% 11.7% 10.9%
Colorado 7.4% 7.4% 8.0% 8.6% 7.7%
Connecticut 6.2% 6.8% 7.2% 8.3% 7.7%
Delaware 6.6% 6.6% 9.0% 12.6% 9.9%
District of Columbia 4.6% 4.9% 4.6% 5.4% 5.6%
Florida 11.4% 11.6% 14.1% 15.8% 16.4%
Georgia 9.2% 9.4% 10.3% 11.0% 12.3%
Hawaii** 10.2% 9.6% 10.1% - 7.8%
Idaho 8.9% 9.2% 10.1% 10.4% 12.9%
Illinois 6.9% 7.9% 8.3% 9.1% 9.4%
Indiana 10.3% 10.0% 11.0% 12.3% 12.7%
Iowa 9.3% 9.4% 10.2% 11.4% 11.4%
Kansas 9.1% 9.8% 10.5% 11.4% 13.0%
Kentucky 12.2% 12.9% 14.1% 13.9% 13.2%
Louisiana 10.0% 10.8% 12.1% 13.5% 14.8%
Maine 7.9% 8.4% 11.6% 13.2% 16.3%
Maryland 6.7% 6.9% 7.6% 7.8% 6.0%
Massachusetts 8.2% 7.8% 8.0% 10.3% 10.8%
Michigan 8.9% 9.2% 10.5% 10.2% 8.6%
Minnesota 5.7% 5.8% 6.2% 6.6% 5.9%
Mississippi 12.9% 12.9% 13.2% 14.6% 16.1%
Missouri 12.6% 12.7% 14.0% 15.3% 14.9%
Montana 8.7% 8.7% 9.3% 11.2% 11.7%
Nebraska 9.4% 10.2% 10.5% 11.5% 12.3%
Nevada 5.8% 6.1% 6.7% 7.1% 7.5%
New Hampshire 7.3% 7.2% 7.7% 8.2% 9.1%
New Jersey 8.5% 9.0% 10.0% 10.4% 10.1%
New Mexico 7.5% 7.1% 7.0% 7.7% 4.8%
New York 3.9% 3.7% 4.1% 5.1% 5.6%
North Carolina 8.0% 8.7% 9.4% 10.7% 11.6%
North Dakota 6.2% 6.6% 7.0% 7.7% 8.1%
Ohio 8.3% 8.6% 9.4% 9.9% 10.5%
Oklahoma** 9.2% 9.6% 9.6% 10.7% -
Oregon 8.3% 6.2% 5.1% 5.0% 6.4%
Pennsylvania 11.6% 11.7% 11.5% 11.8% 8.6%
Rhode Island 5.8% 7.1% 6.7% 7.1% 6.7%
South Carolina 7.9% 8.7% 9.4% 9.9% 11.1%
South Dakota 6.7% 7.1% 7.6% 8.7% 8.7%
Tennessee 3.9% 0.0% 0.0% 0.0% 0.0%
Texas 8.3% 8.8% 9.7% 10.2% 11.5%
Utah 8.8% 9.6% 11.4% 12.0% 11.1%
Vermont 10.9% 10.5% 12.1% 14.4% 12.4%
Virginia 11.4% 11.6% 12.5% 13.4% 13.4%
Washington 10.7% 11.1% 12.4% 14.7% 12.0%
West Virginia 9.7% 11.2% 11.1% 10.6% 12.0%
Wisconsin 10.1% 10.1% 10.8% 10.9% 10.5%
Wyoming 6.7% 7.0% 7.5% 8.1% 8.9%

*National figures include Puerto Rico and the Virgin Islands.


**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

4-22 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Share of Drug Payments, Top 5 Therapeutic Categories, 1999


Analgesics and Cardiovascular Miscellaneous Psycho-
State Antipyretics Antibiotics Drugs GI Drugs Therapeutics
National Average 6.5% 5.4% 6.1% 8.8% 20.1%
Alabama 5.1% 9.2% 8.1% 9.3% 14.9%
Alaska 10.5% 5.8% 4.3% 8.3% 19.5%
Arizona* - - - - -
Arkansas 6.0% 6.4% 8.0% 9.0% 17.3%
California 5.2% 3.6% 7.7% 8.6% 17.2%
Colorado* - - - - -
Connecticut 5.5% 3.5% 6.5% 7.4% 24.5%
Delaware 7.0% 6.3% 5.1% 7.8% 15.0%
District of Columbia 3.3% 4.1% 8.8% 3.6% 13.1%
Florida 6.1% 5.8% 5.4% 8.4% 13.2%
Georgia 6.8% 8.6% 7.4% 8.1% 15.4%
Hawaii 6.1% 3.7% 7.6% 3.2% 19.5%
Idaho 7.7% 5.4% 3.7% 11.2% 22.0%
Illinois 5.3% 6.3% 6.4% 8.7% 18.6%
Indiana 7.2% 5.2% 5.1% 9.9% 19.1%
Iowa 5.6% 5.7% 5.3% 6.7% 22.6%
Kansas 7.2% 5.5% 5.3% 10.1% 22.9%
Kentucky 5.7% 6.7% 6.6% 13.1% 18.0%
Louisiana 7.7% 7.9% 7.1% 8.4% 13.0%
Maine 8.0% 4.0% 5.2% 11.4% 20.5%
Maryland 4.0% 2.7% 6.2% 7.0% 28.0%
Massachusetts 5.3% 3.9% 5.5% 7.9% 25.6%
Michigan 7.3% 4.3% 7.2% 8.4% 19.4%
Minnesota 5.1% 3.9% 4.2% 7.5% 28.7%
Mississippi* - - - - -
Missouri 7.1% 5.0% 6.1% 10.4% 19.8%
Montana 7.1% 5.4% 4.5% 9.8% 21.0%
Nebraska 7.2% 7.3% 5.0% 9.7% 19.4%
Nevada 8.1% 7.0% 5.8% 8.7% 18.5%
New Hampshire 6.9% 3.6% 4.4% 8.9% 25.9%
New Jersey 6.1% 3.3% 6.1% 8.9% 15.6%
New Mexico 7.5% 3.8% 7.2% 12.3% 16.9%
New York 5.0% 5.0% 6.6% 7.1% 16.7%
North Carolina 6.4% 6.6% 7.1% 10.6% 14.6%
North Dakota 6.2% 5.4% 5.8% 8.9% 22.9%
Ohio 7.1% 4.9% 6.2% 10.3% 20.1%
Oklahoma 7.6% 6.7% 6.8% 8.8% 17.5%
Oregon 5.2% 2.7% 3.6% 3.7% 47.2%
Pennsylvania 5.9% 5.1% 6.7% 9.2% 19.3%
Rhode Island 4.8% 3.8% 7.5% 10.1% 23.6%
South Carolina 7.1% 6.5% 8.3% 9.8% 14.5%
South Dakota 6.0% 7.7% 5.3% 9.1% 18.5%
Tennessee* - - - - -
Texas* - - - - -
Utah 7.0% 7.4% 3.4% 8.7% 24.3%
Vermont 7.4% 3.7% 6.3% 12.0% 18.8%
Virginia 6.5% 5.4% 6.5% 10.6% 15.8%
Washington 8.0% 3.6% 5.3% 9.6% 22.0%
West Virginia 5.8% 8.0% 6.5% 5.8% 18.3%
Wisconsin 6.9% 3.5% 6.2% 7.4% 24.7%
Wyoming 6.9% 7.1% 4.2% 9.1% 20.7%
*Data not reported for Arizona, Colorado, Mississippi, Tennessee, or Texas.

Source: The Lewin Group analysis of HCFA Drug Utilization data, FY99.

National Pharmaceutical Council 4-23


Pharmaceutical Benefits 2000

Total Drug Recipients‡


State 1994 1995 1996 1997 1998
National Total* 24,473,189 23,723,349 22,585,295 20,954,163 19,337,543
Alabama 409,406 404,581 412,511 412,739 395,290
Alaska 40,812 40,076 40,839 42,174 43,734
Arizona 63,944 66,860 63,103 80,450 56,796
Arkansas 257,861 253,181 255,211 254,079 262,907
California 3,796,517 3,656,783 3,565,667 3,158,386 2,644,430
Colorado 209,290 196,737 173,707 156,631 147,033
Connecticut 255,218 273,511 209,557 120,522 108,331
Delaware 54,384 56,710 61,380 68,672 69,027
District of Columbia 68,211 53,992 66,349 64,494 57,733
Florida 1,197,915 1,111,466 1,079,467 1,024,555 1,014,372
Georgia 825,875 875,647 891,335 846,963 805,923
Hawaii** 95,805 28,971 29,657 - 32,222
Idaho 81,394 81,755 84,553 79,961 86,775
Illinois 1,054,436 1,134,214 1,028,753 1,008,740 959,472
Indiana 480,648 428,116 401,042 352,814 323,811
Iowa 237,667 231,256 230,749 221,061 215,173
Kansas 184,400 186,362 179,653 170,167 155,875
Kentucky 493,689 491,370 497,251 494,293 429,102
Louisiana 604,163 598,579 593,415 563,864 552,481
Maine 136,623 120,029 138,360 139,524 137,816
Maryland 299,875 291,626 268,440 256,423 176,403
Massachusetts 531,851 558,233 527,114 559,215 613,186
Michigan 863,391 823,485 763,232 688,882 589,818
Minnesota 294,307 305,363 294,589 227,027 203,220
Mississippi 411,813 416,065 404,263 391,328 368,609
Missouri 543,833 561,167 469,821 395,478 353,902
Montana 68,661 67,244 66,465 62,092 58,641
Nebraska 128,501 131,974 138,322 151,973 145,408
Nevada 55,336 59,170 60,274 55,876 50,903
New Hampshire 67,200 73,938 75,701 71,692 70,339
New Jersey 611,638 612,074 518,833 347,105 309,849
New Mexico 172,752 178,087 197,565 184,502 96,637
New York 1,920,814 1,880,506 1,737,372 1,667,927 1,803,428
North Carolina 653,792 737,558 764,482 779,229 764,886
North Dakota 42,442 41,128 40,062 39,654 37,675
Ohio 1,023,733 1,007,970 902,211 786,322 702,143
Oklahoma** 283,428 285,654 245,075 207,441 -
Oregon 227,825 181,553 154,801 149,461 148,258
Pennsylvania 996,129 941,013 857,818 763,255 580,749
Rhode Island 57,942 93,639 52,239 46,817 44,852
South Carolina 355,545 365,571 365,409 359,910 401,611
South Dakota 47,614 47,969 49,056 47,845 46,588
Tennessee 454,323 1,395 18 3 1
Texas 1,989,651 2,020,864 2,058,903 1,986,178 1,894,447
Utah 120,093 119,776 114,321 105,676 126,953
Vermont 74,224 78,694 78,376 83,057 58,037
Virginia 470,048 480,405 417,580 396,719 383,880
Washington 495,379 405,558 305,791 292,733 274,463
West Virginia 273,714 295,210 299,967 280,550 267,398
Wisconsin 342,705 329,711 309,582 265,987 221,508
Wyoming 35,964 35,505 35,415 33,426 32,510

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
*National figures include Puerto Rico and the Virgin Islands.
**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

4-24 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Drug Payments Per Recipient‡


State 1994 1995 1996 1997 1998
National* $363 $413 $474 $571 $699
Alabama $398 $442 $494 $548 $599
Alaska $410 $461 $530 $673 $752
Arizona $18 $30 $39 $23 $25
Arkansas $342 $403 $451 $534 $574
California $296 $313 $343 $423 $587
Colorado $337 $401 $475 $619 $749
Connecticut $472 $531 $701 $1,383 $1,722
Delaware $337 $378 $452 $505 $599
District of Columbia $370 $486 $494 $582 $715
Florida $404 $501 $610 $754 $921
Georgia $315 $329 $358 $401 $460
Hawaii** $360 $856 $905 - $1,230
Idaho $361 $406 $485 $563 $633
Illinois $314 $389 $434 $519 $608
Indiana $484 $438 $671 $831 $1,006
Iowa $384 $421 $483 $560 $684
Kansas $387 $437 $505 $615 $762
Kentucky $440 $512 $548 $640 $746
Louisiana $445 $488 $501 $559 $639
Maine $469 $532 $606 $735 $884
Maryland $418 $477 $577 $674 $842
Massachusetts $472 $552 $575 $712 $811
Michigan $336 $379 $462 $530 $634
Minnesota $387 $486 $510 $686 $854
Mississippi $340 $391 $437 $533 $629
Missouri $420 $463 $600 $811 $1,081
Montana $382 $421 $493 $571 $723
Nebraska $432 $468 $517 $525 $637
Nevada $319 $360 $405 $477 $678
New Hampshire $423 $461 $559 $633 $787
New Jersey $504 $562 $721 $1,065 $1,375
New Mexico $277 $284 $310 $343 $430
New York $379 $436 $522 $654 $759
North Carolina $329 $376 $451 $518 $610
North Dakota $416 $479 $522 $636 $733
Ohio $406 $476 $575 $738 $919
Oklahoma** $315 $353 $401 $535 -
Oregon $377 $455 $433 $490 $592
Pennsylvania $491 $578 $626 $724 $904
Rhode Island $686 $511 $874 $1,114 $1,369
South Carolina $312 $341 $394 $443 $560
South Dakota $399 $450 $492 $577 $668
Tennessee $168 $137 $852 $373 $36
Texas $257 $286 $324 $378 $432
Utah $331 $371 $421 $481 $542
Vermont $382 $428 $466 $533 $749
Virginia $417 $444 $530 $629 $741
Washington $340 $398 $565 $700 $891
West Virginia $390 $442 $417 $474 $557
Wisconsin $536 $578 $664 $773 $1,049
Wyoming $291 $335 $385 $445 $527

‡Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
*National figures include Puerto Rico and the Virgin Islands.
**Hawaii and Oklahoma did not submit detail drug information for 1997 and 1998, respectively.
Source: The Lewin Group analysis of HCFA, CMSO, HCFA-2082 Report, FY94-FY98.

National Pharmaceutical Council 4-25


Pharmaceutical Benefits 2000

Medicaid Drug Reimbursement Report, 1998


Drug Drug Prescriptions Average
State Payments1 Recipients1 Processed2 Prescription Cost2
Alabama $236,674,147 395,290 7,852,261 $30.34
Alaska $32,887,828 43,734 662,575 $51.73
Arizona* $1,442,917 56,796 - -
Arkansas $150,891,615 262,907 3,142,993 $37.44
California $1,553,598,462 2,644,430 40,646,534 $40.56
Colorado $110,159,725 147,033 1,431,595 $37.14
Connecticut* $186,593,992 108,331 - -
Delaware $41,350,537 69,027 830,829 $38.68
District of Columbia $41,254,973 57,733 1,858,364 $43.83
Florida $933,782,041 1,014,372 18,681,483 $47.86
Georgia $370,562,935 805,923 9,284,700 $31.24
Hawaii $39,623,380 32,222 1,119,545 $34.40
Idaho $54,971,097 86,775 630,770 $42.21
Illinois $583,239,675 959,472 17,981,685 $34.01
Indiana $325,712,348 323,811 4,379,620 $40.46
Iowa $147,115,884 215,173 4,457,957 $19.70
Kansas* $118,825,316 155,875 - -
Kentucky $319,983,951 429,102 9,630,473 $33.41
Louisiana $352,784,785 552,481 20,664,690 $34.35
Maine $121,771,298 137,816 2,868,068 $41.85
Maryland $148,532,940 176,403 2,336,929 $42.54
Massachusetts $497,146,531 613,186 12,598,550 $40.18
Michigan $374,145,567 589,818 10,357,765 $34.23
Minnesota $173,602,492 203,220 4,612,393 $35.23
Mississippi $231,735,360 368,609 5,368,429 $40.27
Missouri $382,512,566 353,902 9,860,308 $38.58
Montana $42,368,399 58,641 1,179,484 $34.74
Nebraska $92,558,539 145,408 2,991,257 $33.36
Nevada $34,518,901 50,903 814,185 $43.14
New Hampshire $55,374,478 70,339 1,572,638 $34.11
New Jersey $426,075,488 309,849 8,400,194 $47.83
New Mexico $41,507,229 96,637 1,176,851 $33.36
New York $1,368,451,273 1,803,428 35,512,292 $44.45
North Carolina $466,528,812 764,886 11,633,909 $41.24
North Dakota $27,619,684 37,675 585,260 $35.44
Ohio $645,118,962 702,143 19,983,451 $33.15
Oklahoma** - - 3,449,399 $41.07
Oregon $87,805,350 148,258 2,374,283 $40.56
Pennsylvania $525,261,211 580,749 14,219,369 $38.75
Rhode Island $61,401,958 44,852 1,570,662 $41.26
South Carolina $224,962,203 401,611 3,555,427 $49.21
South Dakota $31,106,511 46,588 762,406 $37.17
Tennessee* $36 1 - -
Texas* $817,591,112 1,894,447 - -
Utah $68,827,853 126,953 2,063,349 $34.25
Vermont $43,445,887 58,037 799,552 $39.94
Virginia $284,578,558 383,880 8,098,755 $35.70
Washington $244,478,658 274,463 6,552,127 $37.60
West Virginia $148,962,081 267,398 5,370,453 $30.13
Wisconsin $232,326,359 221,508 6,358,445 $36.87
Wyoming $17,138,952 32,510 453,071 $39.98

*Data not reported for Arizona, Connecticut, Kansas, Tennessee, or Texas.


**Oklahoma did not submit detailed information for 1998.
Source: 1HCFA, CMSO, HCFA-2082 Report, FY98. 2The Lewin Group analysis of HCFA Drug Utilization data, Fiscal Year 1998.

4-26 National Pharmaceutical Council


Pharmaceutical Benefits 2000

MEDICAID DRUG REBATES


In 1990, Congress considered a number of proposals designed to reduce and control federal and state expenditures
for prescription drug products provided to Medicaid patients (S.2605, the Pharmaceutical Access and Prudent
Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug Act, sponsored by Senator David Pryor; and
H.R.5589, the Medicaid Prescription Drug Fair Access and Pricing Act, sponsored by Representatives Ron
Wyden and Jim Cooper). Following the introduction of this legislation, several pharmaceutical manufacturers
voluntarily offered rebates to the states in exchange for open access for their products, while the Pharmaceutical
Manufacturers Association proposed a set rebate amount in exchange for open formularies.

In the course of the budget debate, the Office of Management and Budget (OMB) incorporated various
components of these proposals into the budget bill, the Omnibus Budget Reconciliation Act of 1990 (OBRA `90).
The resulting Public Law 101-508, enacted November 5, 1990, required a drug manufacturer to enter into and
have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services
(HHS) for States to receive federal funding for outpatient drugs dispensed to Medicaid patients.

The requirement for rebate agreements does not apply to the dispensing of a single-source or innovator multiple-
source drug if the state has determined that the drug is essential, rated 1-A by the FDA, and prior authorization is
obtained for the exception. Existing rebate agreements qualify under the law if the state agrees to report all
rebates to HHS and the agreement provides for a minimum aggregate rebate of 10% of the state’s expenditures for
the manufacturer’s products.

OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug manufacturer to
enter into discount pricing agreements with the Department of Veterans Affairs and with covered entities funded
by the Public Health Service in order to have its drugs covered by Medicaid. The Medicaid rebate law, as
amended, is included as Appendix C.

The drug rebate program is administered by HCFA's Center for Medicaid and State Operations (CMSO).
Currently, the rebate for covered outpatient drugs is as follows:

• For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1 percent of
the average manufacturer’s price (AMP) or the difference between the AMP and the manufacturer’s "best
price," and (2) an additional rebate for any price increase for a product that exceeds the increase in the
Consumer Price Index (CPI-U) for all items since the fall of 1990. AMP is the average price paid by
wholesalers for products distributed to the retail class of trade. The best price is the lowest price offered
to any other customer, excluding Federal Supply Schedule prices, prices to state pharmaceutical
assistance programs, and prices that are nominal in amount, and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of each
product’s AMP.

National Pharmaceutical Council 4-27


Pharmaceutical Benefits 2000

Medicaid Drug Rebates


Allocation of 1999 1999
State Drug Rebate Moneys1 Total Rebates2 Federal Share2
National Total $3,316,594,880 $1,899,896,508
Alabama Medicaid Drug Budget $49,785,076 $34,533,102
Alaska General Fund $7,050,981 $4,216,486
Arizona* - - -
Arkansas Medicaid General $37,931,853 $27,703,515
California Medicaid Drug Budget $533,191,914 $278,960,679
Colorado Medicaid General $25,150,259 $12,868,802
Connecticut General Fund $38,656,394 $19,328,198
Delaware Medicaid General $9,787,444 $4,945,369
District of Columbia Medicaid General $8,379,982 $5,866,114
Florida Medicaid Drug Budget $195,512,719 $109,644,101
Georgia General Fund $94,903,175 $57,612,243
Hawaii General Fund $8,378,292 $4,189,146
Idaho Medicaid General $11,901,778 $8,313,393
Illinois General Fund $121,540,781 $61,133,375
Indiana General Fund $62,691,135 $38,247,862
Iowa General Fund $32,369,409 $20,570,660
Kansas General Fund $26,878,486 $16,184,126
Kentucky Medicaid General $72,676,810 $51,258,954
Louisiana Medicaid Drug Budget $76,147,317 $53,686,416
Maine General Fund $30,032,364 $19,941,489
Maryland Medicaid General $32,403,851 $16,274,193
Massachusetts General Fund $140,102,747 $70,660,841
Michigan Medicaid Drug Budget $75,674,128 $39,969,595
Minnesota Medicaid General $37,389,033 $19,255,352
Mississippi Medicaid Special Refund $49,332,307 $37,964,206
Missouri Medicaid Drug Budget $84,620,799 $51,306,706
Montana General Fund $9,290,653 $6,688,938
Nebraska General Fund and Medicaid General $21,609,490 $13,454,079
Nevada Medicaid Drug Budget $7,727,267 $3,882,559
New Hampshire General Fund $12,956,727 $6,478,364
New Jersey Medicaid Drug Budget $89,197,702 $44,750,228
New Mexico General Fund $7,972,600 $5,818,404
New York General Fund $356,088,488 $178,044,244
North Carolina Medicaid General $111,326,116 $70,372,764
North Dakota Medicaid General $5,954,387 $4,171,965
Ohio Medicaid General $148,477,399 $86,502,933
Oklahoma Medicaid General $31,992,100 $22,786,690
Oregon General Fund $21,360,688 $13,062,439
Pennsylvania Medicaid Drug Budget- $119,340,064 $64,407,705
Rhode Island Medicaid General $14,440,971 $7,805,345
South Carolina Medicaid Drug Budget $55,971,288 $39,382,765
South Dakota Medicaid General $5,971,015 $4,094,537
Tennessee - $22,434,760 $14,154,090
Texas Medicaid Drug Budget $185,695,267 $116,237,687
Utah General Fund $14,721,050 $10,566,770
Vermont Medicaid General $10,579,999 $6,556,425
Virginia Medicaid Medical Budget $67,715,512 $35,066,017
Washington General Fund $54,331,249 $28,566,897
West Virginia Medicaid General $35,941,495 $26,765,632
Wisconsin Medicaid Drug Budget $38,644,764 $22,837,194
Wyoming Medicaid Drug Budget $4,364,795 $2,806,914

*Does not apply for Arizona.


Sources: 1As reported by state drug program administrators in the 2000 NPC Survey.
2
HCFA 64, Medicaid Financial Management Report, FY99.

4-28 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Medicaid Drug Rebate Trends, 1995-1999


1995 1996 1997 1998 1999
State Drug Rebate Drug Rebate Drug Rebate Drug Rebate Drug Rebate
National Total $1,795,369,481 $1,961,842,019 $2,212,579,458 $2,469,136,949 $3,316,594,880
Alabama $26,713,236 $35,746,548 $47,135,670 $36,537,095 $49,785,076
Alaska $3,392,270 $3,631,600 $4,900,641 $5,026,624 $7,050,981
Arizona* - - - - -
Arkansas $15,838,282 $19,942,216 $24,514,373 $22,518,230 $37,931,853
California $214,571,699 $259,522,046 $307,645,326 $362,808,597 $533,191,914
Colorado $16,164,945 $17,354,887 $16,950,071 $20,424,896 $25,150,259
Connecticut $29,670,883 $30,787,226 $27,318,565 $32,128,587 $38,656,394
Delaware $39,108,649 $4,424,652 $5,851,285 $7,096,836 $9,787,444
District of Columbia $6,212,050 $5,669,258 $6,668,493 $7,100,983 $8,379,982
Florida $99,995,743 $110,282,689 $128,466,755 $150,733,077 $195,512,719
Georgia $51,400,489 $56,905,277 $59,756,017 $64,320,077 $94,903,175
Hawaii $5,451,328 $3,720,038 $4,654,126 $5,992,722 $8,378,292
Idaho $5,364,698 $6,534,816 $8,369,523 $8,614,444 $11,901,778
Illinois $68,635,826 $85,146,120 $85,128,380 $100,811,862 $121,540,781
Indiana $39,660,999 $45,845,822 $43,645,256 $50,710,861 $62,691,135
Iowa $17,082,336 $18,770,263 $21,755,142 $25,265,390 $32,369,409
Kansas $13,274,426 $16,682,962 $11,797,675 $19,852,439 $26,878,486
Kentucky $42,282,025 $43,116,489 $59,890,925 $57,082,387 $72,676,810
Louisiana $49,319,520 $55,702,577 $54,650,344 $65,994,910 $76,147,317
Maine $13,111,934 $16,131,900 $18,246,061 $19,650,719 $30,032,364
Maryland $25,339,673 $28,493,983 $34,567,082 $25,017,660 $32,403,851
Massachusetts $53,656,921 $65,037,309 $73,047,452 $89,011,664 $140,102,747
Michigan $64,564,101 $67,989,816 $74,116,928 $72,526,027 $75,674,128
Minnesota N/A $6,992,875 $31,873,349 $31,058,740 $37,389,033
Mississippi $30,380,557 $32,191,139 $37,108,638 $39,983,265 $49,332,307
Missouri $45,080,603 $51,527,496 $54,614,194 $66,460,159 $84,620,799
Montana $5,565,740 $6,031,657 $6,775,176 $7,378,206 $9,290,653
Nebraska $10,418,227 $12,330,363 $14,931,313 $16,545,572 $21,609,490
Nevada $4,038,721 $4,400,121 $5,391,025 $5,143,136 $7,727,267
New Hampshire $5,046,055 $7,912,982 $8,788,296 $9,676,461 $12,956,727
New Jersey $62,240,335 $65,377,388 $66,748,605 $70,992,525 $89,197,702
New Mexico $9,071,911 $11,509,943 $13,367,028 $10,670,766 $7,972,600
New York $151,313,836 $150,547,790 $200,157,978 $251,273,382 $356,088,488
North Carolina $43,275,244 $57,099,702 $68,332,867 $81,211,796 $111,326,116
North Dakota $3,548,429 $3,734,060 $4,651,348 $4,990,065 $5,954,387
Ohio $97,259,136 $103,428,427 $84,238,194 $110,484,575 $148,477,399
Oklahoma $18,519,577 $19,696,492 $20,776,998 $23,329,251 $31,992,100
Oregon $18,887,522 $19,668,133 $13,852,833 $14,433,179 $21,360,688
Pennsylvania $89,645,272 $99,204,380 $115,510,606 $95,692,149 $119,340,064
Rhode Island $8,904,676 $9,336,162 $10,121,820 $11,041,552 $14,440,971
South Carolina $27,588,863 $30,483,825 $34,643,502 $39,156,574 $55,971,288
South Dakota $3,248,482 $3,248,037 $4,940,121 $5,070,643 $5,971,015
Tennessee $1,110,475 $247,255 - $840 $22,434,760
Texas $106,027,639 $114,442,343 $130,576,891 $145,635,499 $185,695,267
Utah $7,608,692 $9,145,247 $8,374,299 $9,988,037 $14,721,050
Vermont $7,363,796 $6,794,891 $8,255,707 $8,868,263 $10,579,999
Virginia $49,153,407 $41,059,487 $45,240,474 $51,079,391 $67,715,512
Washington $33,803,617 $33,586,091 $38,326,646 $39,191,376 $54,331,249
West Virginia $20,248,539 $27,287,834 $26,079,819 $26,753,285 $35,941,495
Wisconsin $32,786,506 $34,494,898 $37,146,544 $40,776,543 $38,644,764
Wyoming $2,421,591 $2,624,507 $2,679,097 $3,025,632 $4,364,795

*Does not apply for Arizona.


Source: HCFA 64, Medicaid Financial Management Report, FY95-FY99.

National Pharmaceutical Council 4-29


Pharmaceutical Benefits 2000

4-30 National Pharmaceutical Council


Pharmaceutical Benefits 2000

MEDICAID DRUG COVERAGE


In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement are covered
outpatient drugs reimbursable by Medicaid. Under the Omnibus Budget Reconciliation Act of 1993, a state
Medicaid program may require prior approval before dispensing of any drug product and may design and
implement a formulary intended to limit coverage for specific drugs. Drug formularies and prior authorization
programs must meet specific requirements established in Medicaid law.

A state Medicaid program can restrict coverage for a drug product through a formulary, if based on official
labeling or information in designated official medical compendia, “the excluded drug does not have a significant,
clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcome of such
treatment” over other drug products, and there is a written explanation (available to the public) of the basis for the
exclusion. However, drug products excluded from the formulary under these conditions, nevertheless, must be
available through prior authorization.

Drugs in certain specific classes may be restricted or excluded from coverage without regard to the formulary
conditions and need not be available through prior authorization. These classes include:

• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic relief of cough
or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal vitamins and fluoride preparations) or non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the manufacturer or his
designee.
• Barbiturates or benzodiazepines.

PRIOR AUTHORIZATION

Whether or not a drug product is on a formulary, states may require physicians to request and receive official
permission before a particular product can be dispensed. This procedure is called Prior Authorization or Prior
Approval.

States may not operate prior authorization plans unless the state provides for a response within 24 hours of a
request and provides for a 72-hour emergency supply of the medication.

The Congressional intent for the prior authorization provision was not to encourage the use of such programs, but
rather to make them available to the states for the purpose of controlling utilization of products that have very
narrow indications or high abuse potential.

The majority of states report the establishment of prior authorization programs and have plans to apply prior
authorization to a select number of drugs. Some states will do so only after their Drug Utilization Review (DUR)
program has identified areas of therapeutic concern.

DRUG UTILIZATION REVIEW

Drug Utilization Review (DUR) is defined as a structured and continuing program that reviews, analyzes, and
interprets patterns of drug usage in a given health care environment against predetermined standards.

The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in containing
health care costs. While there is a general belief that DUR is cost beneficial, it is difficult to isolate concrete

National Pharmaceutical Council 4-31


Pharmaceutical Benefits 2000

evidence that supports this view. The primary issue facing Medicaid DUR programs is whether or not the
systems currently in place (or envisioned) meet the two objectives outlined above.

OBRA `90 required that, by January 1, 1993, states had to establish a Drug Utilization Review (DUR) program,
consisting of prospective and retrospective components as well as components to educate physicians and
pharmacists on common drug therapy problems and assessments of whether usage complies with predetermined
standards.

Prospective DUR is to be conducted at the point of sale (POS) before delivery of a medication by the pharmacist
to the Medicaid recipient or caregiver. The state is to establish standards for counseling patients and will require
the pharmacist to offer to discuss matters, which, in the exercise of the pharmacist’s professional judgement are
deemed significant, including the following:

• Name and description of the medication;


• The route of administration, dosage form, dosage, and duration of therapy;
• Special directions and precautions for preparation, administration and use by the patient;
• Common severe side or adverse effects or interactions and therapeutic contraindications that may be
encountered, including their avoidance, and the action required if they occur;
• Techniques for self-monitoring prescription therapy;
• Proper storage;
• Prescription refill information; and
• Action to be taken in the event of a missed dose.
State law must also require pharmacists to make a reasonable effort to obtain, record, and maintain at least the
following information for each Medicaid recipient:

• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and drug
reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
OBRA `90 required that retrospective review is to be ongoing, based on compendia standards and medical
literature, and to include remedial strategies for educational outreach through a wide range of interventions. Each
state is to establish a Drug Utilization Review board, consisting of no more than 51% physicians and at least one-
third pharmacists.

4-32 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Pharmacy Advisory Committees


State Pharmacy Advisory Committee Meetings Preferred Product Introduction Process
Alabama Pharmacy & Therapeutic Committee Bi-Monthly Contact First Data Bank
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas N/A - Introductory letter
California Contract Drug Advisory Committee Ad Hoc Introductory letter
Colorado DUR Board advises Quarterly Introductory letter
Connecticut None - Introductory letter
Delaware DUR Board advises Bi-Monthly Introductory letter
District of Columbia N/A - Introductory letter
Florida DUR Board advises Quarterly Introductory letter
Georgia Yes Quarterly Introductory letter
Hawaii DUR Board advises Quarterly Introductory letter
Idaho DUR Board advises Bi-Monthly Introductory letter
Illinois No - Contact First Data Bank
Indiana DUR Board advises Quarterly Introductory letter
Iowa Medicaid Pharmacy Advisory Committee Semiannually Introductory letter
Kansas DUR Board advises Bi-Monthly Introductory letter, Formulary packet
Kentucky Drug Management Review Advisory Board Quarterly State form, Package insert
Louisiana Benefits Management Advisory Committee Ad Hoc Introductory letter
Maine DUR Committee Bi-Monthly Introductory letter
Maryland No - Introductory letter
Massachusetts DUR Committee Quarterly Introductory letter
Michigan No - State form
Minnesota Drug Formulary Committee Quarterly Introductory letter
Mississippi No - Introductory letter
Missouri Pharmacy Subcommittee Quarterly Introductory letter
Montana DUR Board advises Monthly Introductory letter
Nebraska Medicaid Pharmacy Advisory Committee Ad Hoc Introductory letter
Nevada None - Introductory letter
New Hampshire None - Introductory letter, FDA updates
New Jersey None - Introductory letter
New Mexico N/A - Introductory letter
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina None - Introductory letter, Package insert
North Dakota None - Introductory letter
Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter
Oklahoma Yes Monthly Introductory letter
Oregon None Contact First Data Bank
Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter
Rhode Island N/A - Introductory letter
South Carolina None - Formulary packet
South Dakota None - Introductory letter
Tennessee* - - -
Texas None - Introductory letter, State form
Utah DUR Committee Monthly Introductory letter
Vermont DUR Committee Bi-Monthly Introductory letter
Virginia Pharmacy Liaison Committee Bi-Monthly Introductory letter
Washington Drug Utilization and Education Council Bi-Monthly State form
West Virginia Medical Services Fund Advisory Council Quarterly Introductory letter
Wisconsin None - Introductory letter
Wyoming None Bi-Monthly Introductory letter, Contact First Data Bank

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-33


Pharmaceutical Benefits 2000

Pharmacy Benefit Design - Coverage


State Cosmetics Fertility Drugs Experiment Drugs
Alabama PA Required Not Covered Not Covered
Alaska Not Covered Not Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Not Covered Not Covered Not Covered
Colorado Not Covered Not Covered Not Covered
Connecticut Not Covered Not Covered Not Covered
Delaware Not Covered Not Covered Not Covered
District of Columbia N/A N/A N/A
Florida Not Covered Not Covered Not Covered
Georgia Not Covered Not Covered Not Covered
Hawaii Not Covered Not Covered Not Covered
Idaho Not Covered Not Covered Not Covered
Illinois Not Covered Not Covered Not Covered
Indiana Not Covered Not Covered Not Covered
Iowa Not Covered Not Covered Not Covered
Kansas Not Covered Not Covered Not Covered
Kentucky Covered Covered Covered
Louisiana Not Covered Not Covered Not Covered
Maine Not Covered Not Covered Not Covered
Maryland Not Covered Not Covered Not Covered
Massachusetts Not Covered Not Covered Not Covered
Michigan Not Covered Not Covered Not Covered
Minnesota Covered Covered Covered
Mississippi Not Covered Not Covered Not Covered
Missouri Not Covered Not Covered Not Covered
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Not Covered Not Covered
New Hampshire Not Covered Not Covered Not Covered
New Jersey Not Covered Not Covered Not Covered
New Mexico Not Covered Not Covered Not Covered
New York Covered Covered Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Not Covered Not Covered Not Covered
Ohio Not Covered Not Covered Not Covered
Oklahoma Not Covered Not Covered Not Covered
Oregon PA Required Not Covered Not Covered
Pennsylvania Not Covered Not Covered Not Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Covered
South Dakota Not Covered Not Covered Not Covered
Tennessee* - - -
Texas Not Covered Not Covered Not Covered
Utah Not Covered Not Covered Not Covered
Vermont Not Covered Not Covered Not Covered
Virginia Not Covered Covered with Restrictions Not Covered
Washington Not Covered Not Covered Not Covered
West Virginia Not Covered Not Covered Not Covered
Wisconsin Not Covered Not Covered Not Covered
Wyoming Covered with Restrictions Not Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-34 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Pharmacy Benefit Design – Coverage (Con’t)


Disposable Needles for Syringe Combinations Blood Glucose Test
State Prescribed Insulin Insulin Use for Insulin Use Strips
Alabama Covered Covered Covered Covered
Alaska Covered Covered Covered Covered
Arizona* - - - -
Arkansas Covered with Restrictions Covered with Restrictions Covered Not Covered
California Covered Covered Covered Covered
Colorado Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered Covered Covered Covered
Delaware Covered Covered Covered Covered
District of Columbia N/A N/A N/A N/A
Florida Covered Covered Covered Covered
Georgia Covered Covered Covered Covered with Restrictions
Hawaii Covered Covered Covered Covered
Idaho Covered Covered Covered Covered as DME
Illinois Covered Covered Covered Covered
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered Covered Covered
Kentucky Not Covered Covered Not Covered Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered Covered
Maryland Covered Covered Covered Not Covered
Massachusetts Covered Covered Covered Covered
Michigan Covered Covered Covered Covered
Minnesota Not Covered Not Covered Not Covered Not Covered
Mississippi Covered Not Covered Covered Covered as DME
Missouri Covered Covered Covered Covered as DME
Montana Covered Not Covered Not Covered Not Covered
Nebraska Covered with Restrictions Not Covered Not Covered Not Covered
Nevada Covered Not Covered Not Covered Not Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Covered Covered
New Mexico Covered Covered Covered Covered
New York Not Covered Not Covered Not Covered Not Covered
North Carolina Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Covered Covered
Ohio Covered as DME Not Covered Not Covered Not Covered
Oklahoma Covered as DME Covered as DME Covered as DME Covered as DME
Oregon Covered Not Covered Covered with Restrictions Not Covered
Pennsylvania Covered Covered Covered Covered
Rhode Island N/A N/A N/A N/A
South Carolina Not Covered Not Covered Not Covered Covered
South Dakota Covered Covered Covered Covered
Tennessee* - - - -
Texas Covered Covered with Restrictions Covered Not Covered
Utah Covered Covered Covered N/A
Vermont Covered Covered Covered Covered
Virginia Covered Covered Covered Covered
Washington Covered Covered Covered Covered
West Virginia Covered Covered as DME Covered as DME Covered as DME
Wisconsin Covered Covered as DME Covered Covered as DME
Wyoming Covered Covered Covered Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-35


Pharmaceutical Benefits 2000

Pharmacy Benefit Design – Coverage (Con’t)


Urine Ketone Total Interdialytic Parenteral
State Test Strips Parenteral Nutrition Nutrition
Alabama Covered Covered Covered
Alaska Covered Covered Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered PA Required PA Required
Colorado Covered with Restrictions PA Required Not Covered
Connecticut Covered Covered Covered
Delaware Covered Covered Not Covered
District of Columbia N/A N/A N/A
Florida Covered with Restrictions Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered Covered Covered
Idaho Covered as DME Covered as DME Covered as DME
Illinois Covered Not Covered Not Covered
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered Covered Covered as DME
Kentucky Covered Not Covered Not Covered
Louisiana Covered PA Required PA Required
Maine Covered Covered Covered
Maryland Not Covered Covered Not Covered
Massachusetts Covered Covered Covered
Michigan Covered Covered as DME Covered as DME
Minnesota Not Covered Not Covered Covered with Restrictions
Mississippi Covered as DME Covered as DME Covered as DME
Missouri Covered as DME Covered as DME Covered as DME
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Covered Not Covered
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Not Covered Not Covered Not Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Covered Covered Covered
Ohio Not Covered Covered as DME Covered as DME
Oklahoma Covered as DME Covered with Restrictions Covered with Restrictions
Oregon Not Covered PA Required PA Required
Pennsylvania Covered Covered Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Covered
South Dakota Covered Not Covered Not Covered
Tennessee* - - -
Texas Not Covered Not Covered Not Covered
Utah Covered Not Covered Not Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered as DME
Washington Covered Covered Covered
West Virginia Covered as DME Covered as DME Not Covered
Wisconsin Covered as DME Covered with Restrictions Covered with Restrictions
Wyoming Covered Covered as DME Covered as DME

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-36 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)

State Physicians Office Home Health Care Extended Care Facility


Alabama PDP PDP PDP
Alaska PP PDP PDP
Arizona* - - -
Arkansas PP PDP PDP
California PP PDP PDP
Colorado PP PDP PDP
Connecticut PP PDP PDP
Delaware PDP and PP PDP PDP
District of Columbia N/A N/A N/A
Florida PP PDP PDP
Georgia PDP and PP PDP PDP
Hawaii PDP and PP PDP PDP
Idaho PDP and PP PDP PDP
Illinois PDP PDP PDP
Indiana PDP and PP PDP and PP PDP and PP
Iowa PP PDP PDP
Kansas PP PDP PDP
Kentucky PDP and PP PDP PDP
Louisiana PDP and PP PDP PDP
Maine PP PDP PDP
Maryland PP PDP PDP
Massachusetts PP PDP PDP
Michigan PP PDP PDP
Minnesota PP PDP and PP PDP
Mississippi PP PDP PDP
Missouri PDP PDP PDP
Montana PP PDP PDP
Nebraska PP PDP PDP
Nevada PP PDP PDP
New Hampshire PP PDP PDP
New Jersey PP PDP PDP
New Mexico PDP and PP PDP and PP PDP and PP
New York PP PDP PDP
North Carolina PP PDP PDP
North Dakota PDP PDP PDP
Ohio PP PDP PDP
Oklahoma PP PDP PDP
Oregon PP PP PP
Pennsylvania PDP PDP PDP
Rhode Island N/A N/A N/A
South Carolina PP PDP PDP
South Dakota PP PP PP
Tennessee* - - -
Texas PP PDP PDP
Utah PP PDP and PP PDP and PP
Vermont PP PP PP
Virginia PP PDP PDP
Washington PP PDP PDP
West Virginia PDP and PP PDP PDP and PP
Wisconsin PP PDP PDP
Wyoming PP PDP PDP
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-37


Pharmaceutical Benefits 2000

Coverage of Vaccines and Unit Dose


State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama EPSDT, VCP Yes
Alaska EPSDT, CHIP, VCP Yes
Arizona* - -
Arkansas VCP Yes
California VCP No
Colorado VCP No
Connecticut CHIP No
Delaware VCP No
District of Columbia EPSDT No
Florida VCP Yes
Georgia EPSDT, CHIP, VCP Yes
Hawaii EPSDT, VCP Yes
Idaho EPSDT, CHIP, VCP Yes
Illinois Special Program No
Indiana EPSDT, CHIP, VCP No
Iowa EPSDT, VCP Yes
Kansas CHIP, VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Services Yes
Louisiana EPSDT, VCP No
Maine EPSDT Yes
Maryland EPSDT Yes, LTC
Massachusetts EPSDT No
Michigan EPSDT, CHIP Yes
Minnesota EPSDT, CHIP, VCP Yes
Mississippi EPSDT No
Missouri EPSDT, CHIP, VCP Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska EPSDT, CHIP, VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes, LTC
New Jersey EPSDT, VCP Yes, LTC
New Mexico VCP No
New York EPSDT, VCP No
North Carolina Health Check Yes
North Dakota EPSDT No
Ohio VCP No
Oklahoma ESPDT, VCP Yes
Oregon VCP Yes
Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No
Rhode Island N/A No
South Carolina VCP Yes
South Dakota VCP Yes
Tennessee* - -
Texas EPSDT Yes
Utah EPSDT, CHIP, VCP, Medical Services Yes
Vermont EPSDT Yes
Virginia VCP, Health Dept. Yes
Washington EPSDT Yes
West Virginia EPSDT, VCP Yes
Wisconsin VCP Yes
Wyoming EPSDT, CHIP, VCP No
^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children
Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-38 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Coverage of Over-the-Counter Medications


Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered with Rx Covered with Rx Covered with Rx Not Covered
Alaska Not Covered Not Covered Not Covered Not Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Not Covered
California PA Required PA Required PA Required PA Required
Colorado Not Covered Limited Coverage Not Covered Limited Coverage
Connecticut Not Covered Limited Coverage Limited Coverage Not Covered
Delaware Covered Covered Covered Covered
District of Columbia N/A N/A N/A N/A
Florida Limited Coverage Limited Coverage Limited Coverage Covered
Georgia Not Covered Limited Coverage Limited Coverage Not Covered
Hawaii Limited Coverage Limited Coverage Limited Coverage Not Covered
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois Not Covered PA Required PA Required Covered
Indiana N/A N/A N/A N/A
Iowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Kansas Not Covered Covered Limited Coverage Limited Coverage
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Not Covered Covered
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Covered Covered Covered with Restrictions Not Covered
Michigan Limited Coverage Limited Coverage Not Covered Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
Mississippi Not Covered Limited Coverage Limited Coverage Not Covered
Missouri Covered Covered Covered Not Covered
Montana Not Covered Limited Coverage Not Covered Not Covered
Nebraska Covered Covered Covered Not Covered
Nevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Hampshire Covered Covered Covered Covered
New Jersey Limited Coverage Limited Coverage Limited Coverage Not Covered
New Mexico Covered Covered Covered Covered
New York Limited Coverage Limited Coverage Limited Coverage Covered
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered PA Required
Ohio Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Oklahoma Not Covered Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Covered with Restrictions Not Covered
Rhode Island N/A N/A N/A N/A
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Limited Coverage Covered Covered Not Covered
Vermont PA Required PA Required PA Required PA Required
Virginia Covered with Restrictions Covered Covered with Restrictions Not Covered
Washington Limited Coverage Limited Coverage Limited Coverage Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Not Covered Covered Covered with Restrictions Not Covered
Wyoming Limited Coverage Covered Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-39


Pharmaceutical Benefits 2000

Coverage of Over-the-Counter Medications (Con’t)


Digestive Products
State (no H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered with Rx Covered with Rx Not Covered Covered with Rx
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Covered Limited Coverage Limited Coverage
California PA Required PA Required PA Required PA Required
Colorado Not Covered Not Covered Not Covered Not Covered
Connecticut Covered Not Covered Covered Not Covered
Delaware Covered Covered Limited Coverage Limited Coverage
District of Columbia N/A N/A N/A N/A
Florida Not Covered Not Covered Covered with Rx Not Covered
Georgia Not Covered Not Covered Not Covered Not Covered
Hawaii Covered with Restrictions Covered with Restrictions Limited Coverage Limited Coverage
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Covered Not Covered PA Required
Indiana N/A N/A N/A N/A
Iowa Not Covered Not Covered Not Covered Covered with Restrictions
Kansas Not Covered Covered Not Covered Not Covered
Kentucky Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Covered
Maine Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Covered Covered with Restrictions Covered Covered with Restrictions
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Covered Limited Coverage Limited Coverage
Mississippi Not Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Not Covered Limited Coverage
Montana Covered Covered Not Covered Not Covered
Nebraska Covered Covered Covered Covered
Nevada Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Hampshire Covered Covered Covered Covered
New Jersey Not Covered Not Covered Not Covered Covered with Restrictions
New Mexico Covered Covered Covered with Restrictions Covered
New York Limited Coverage Covered Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered Not Covered
Ohio Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Oklahoma Not Covered Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered with Restrictions Covered Covered
Rhode Island N/A N/A N/A N/A
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Covered Covered N/A Limited Coverage
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered Limited Coverage
Washington Covered Not Covered Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Covered Covered
Wisconsin Covered with Restrictions Not Covered Not Covered Covered with Restrictions
Wyoming Not Covered Covered Covered Limited Coverage

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-40 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Prior Authorization Process and Procedures


State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes N/A N/A N/A
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board N/A N/A
California Yes No - -
Colorado Yes Yes N/A N/A
Connecticut No - - -
Delaware Yes No N/A N/A
District of Columbia Yes N/A N/A N/A
Florida Yes No - -
Georgia Yes Yes 14 Quarterly
Hawaii Yes DUR Board 9 Quarterly
Idaho Yes Yes (Used only for Growth Hormones) 3 Ad hoc
Illinois Yes Committee on Drugs and Therapeutics Varies Quarterly
Indiana No - - -
Iowa Yes No - -
Kansas Yes No - -
Kentucky Yes Prior Authorization Subcommittee 6 Quarterly
Louisiana No - - -
Maine Yes No - -
Maryland No - - -
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi No No - -
Missouri Yes Prior Authorization Committee 7 Quarterly
Montana Yes No
Nebraska Yes Utilization Review Committee 7 Ad hoc
Nevada Yes No - -
New Hampshire No - - -
New Jersey Yes No - -
New Mexico Yes No - -
New York No - - -
North Carolina No - - -
North Dakota Yes No - -
Ohio Yes No - -
Oklahoma Yes DUR Board 10 Monthly
Oregon Yes No 12 Quarterly
Pennsylvania Yes No - -
Rhode Island Yes No - -
South Carolina Yes No - -
South Dakota Yes No - -
Tennessee* - - - -
Texas Yes No - -
Utah Yes No - -
Vermont Yes No - -
Virginia Yes Yes N/A Not Active
Washington Yes Drug Utilization and Education Council 8 Bimonthly
West Virginia Yes DUR Board - -
Wisconsin Yes No - -
Wyoming No - - -

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-41


Pharmaceutical Benefits 2000

Prior Authorization Process and Procedures (Con’t)


State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph. N/A N/A
Alaska R.Ph. 3,634 74%
Arizona* - - -
Arkansas M.D., R.Ph. 126,248 83%
California M.D., R.Ph. 1,200,000 87%
Colorado M.D. 12,000 90%
Connecticut N/A N/A N/A
Delaware M.D., R.Ph. 50 N/A
District of Columbia N/A N/A N/A
Florida M.D., R.Ph. N/A N/A
Georgia M.D., R.Ph. 50,000 85%
Hawaii M.D., R.Ph. N/A N/A
Idaho M.D. 1,200 97%
Illinois M.D., R.Ph. 670,000 N/A
Indiana N/A N/A N/A
Iowa M.D., R.Ph. 30,000 80%
Kansas M.D., R.Ph. 10,085 85%
Kentucky M.D., R.Ph., Social Worker 298,244 70%
Louisiana N/A N/A N/A
Maine M.D. 1,500 90%
Maryland M.D., R.Ph 8,640 95%
Massachusetts M.D 14,000 95%
Michigan M.D. 18,000 82%
Minnesota R.Ph. 6,000 96%
Mississippi M.D. 40000 99%
Missouri M.D. 10,000 N/A
Montana M.D., R.Ph., Nurse 12,078 84%
Nebraska M.D., R.Ph. 2,500 80%
Nevada M.D., R.Ph. 40,000 90%
New Hampshire N/A N/A N/A
New Jersey R.Ph., DME Supplier 386,000 90%
New Mexico M.D., R.Ph. 60 80%
New York Order Provider N/A N/A
North Carolina N/A 395 85
North Dakota R.Ph. 625 96%
Ohio M.D. 40,000 99%
Oklahoma M.D., R.Ph. 6,000 75%
Oregon M.D. 24974 70%
Pennsylvania M.D. N/A N/A
Rhode Island R.Ph. 200 N/A
South Carolina M.D., R.Ph. 4,200 90%
South Dakota M.D., R.Ph. 50 95%
Tennessee* - - -
Texas M.D., R.Ph. N/A N/A
Utah R.Ph. N/A N/A
Vermont M.D. N/A 99%
Virginia M.D. N/A N/A
Washington M.D., R.Ph. 82,480 80%
West Virginia M.D., R.Ph. 153,235 73%
Wisconsin R.Ph. 58,321 99%
Wyoming N/A N/A N/A
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-42 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Prior Authorization Process and Procedures (Con’t)


State Reviewer Review Time Response Vehicle
Alabama R.N., M.D., R.Ph. 24 hours Phone, fax, mail
Alaska M.D., R.Ph., other Verbal-instant; paper-2 weeks Verbal, fax, mail
Arizona* - - -
Arkansas Voice Response 1-3 minutes Voice Response System
California R.Ph. 24 hours Fax or telephone inquiry system
Colorado R.Ph., Fiscal Agent PA line Less than 1 working day Phone
Connecticut N/A N/A N/A
Delaware R.Ph. 1 working day Phone, fax
District of Columbia N/A N/A N/A
Florida R.N., R.Ph., Other 10 minutes to 72 hours Verbal, fax, mail
Georgia R.Ph. 24 hours Phone, fax, mail
Hawaii R.N., M.D. 24 hours Phone
Idaho M.D., R.Ph. 24 hours or less Mail, fax
Illinois M.D., R.Ph. 24 hours Automated phone
Indiana N/A N/A N/A
Iowa R.Ph. 24 hours or less Phone, fax
Kansas R.N., M.D., R.Ph. 24 hours or less Phone
Kentucky R.N., M.D., R.Ph. Minutes to hours+ Phone, mail
Louisiana N/A N/A N/A
Maine M.D., R.Ph. 24 hours or less Phone, mail
Maryland M.D., R.Ph. 24 hours or less Phone
Massachusetts R.Ph. 24 hours Phone, on-line
Michigan Health Care Analysts 24 hours or less Phone
Minnesota R.N. Within 10 days Phone, mail
Mississippi R.N., R.Ph., other 5-10 minutes Phone
Missouri R.N., Medicaid Tech. Within 24 hours Phone, fax
Montana R.Ph. 10-15 minutes Phone, fax
Nebraska R.N., M.D., R.Ph. 1 hour Fax, mail
Nevada R.N., M.D., R.Ph. 24 hours Phone, fax, mail
New Hampshire N/A N/A N/A
New Jersey R.N., R.Ph. Minutes Phone
New Mexico R.Ph. 3 minutes Requestor notified if PA is denied
New York R.N., R.Ph., other Under 21 days PA sent to ordering provider
North Carolina R.Ph. 24 hours Fax
North Dakota R.Ph., M.D., R.N. 2-3 days Mail
Ohio R.Ph. 24 hours Phone, fax
Oklahoma R.Ph. 5-20 minutes Phone, fax
Oregon R.Ph. 3-4 minutes Phone, fax
Pennsylvania R.N., M.D. Immediately to 24 hours Phone
Rhode Island R.Ph. Within 72 hours N/A
South Carolina R.Ph. Per OBRA '90 guidelines Phone, fax, mail
South Dakota M.D. or R.Ph. 24 hours Phone, fax, mail
Tennessee* - - -
Texas R.Ph. N/A Phone, fax, mail, e-mail
Utah Nurse 24 hours Phone, fax, mail
Vermont R.N. 24 hours Phone, mail
Virginia M.D., R.Ph. 24 hours Phone, fax, mail
Washington R.N., M.D., R.Ph.# 24 hours Phone, fax; denial through mail
West Virginia R.Ph. 3 minutes to 2 hours Phone, fax
Wisconsin R.Ph. Immediate to a few days+ Phone, fax, mail
Wyoming N/A N/A N/A
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
+
Depends on urgency.
#
Reviewer also includes Medical Claims Examiner.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-43


Pharmaceutical Benefits 2000

Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered, PA Required Covered, PA Required Not Covered
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Covered, PA Required Covered, Some PA Required Covered, PA Required
Colorado Covered, PA Required Covered Partial Coverage
Connecticut Covered Covered Not Covered
Delaware Covered Covered Covered, PA Required
District of Columbia N/A N/A N/A
Florida Covered Covered Not Covered
Georgia Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Hawaii Covered, PA Required Partial Coverage Partial Coverage
Idaho Covered Covered Not Covered
Illinois N/A N/A N/A
Indiana Covered N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Covered, PA Required
Kentucky Covered, PA Required Covered, Some PA Required Not Covered
Louisiana Covered Covered Not Covered
Maine Covered, PA Required Covered Covered, PA Required
Maryland Covered Covered Not Covered
Massachusetts Covered Covered Covered, PA Required
Michigan Not Covered Covered Not Covered
Minnesota Covered Covered Not Covered
Mississippi Covered Covered, PA Required Covered
Missouri Covered Covered Not Covered
Montana Covered Covered, PA Required Covered, PA Required
Nebraska Covered Covered Not Covered
Nevada Covered Covered Not Covered
New Hampshire Covered Covered Not Covered
New Jersey Partial Coverage Covered PA for ADD Diagnosis
New Mexico Covered Covered Covered
New York Covered Covered Not Covered
North Carolina Covered Covered Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered, PA Required Covered Not Covered
Oklahoma Not Covered Covered, PA Required Not Covered
Oregon Covered Covered Covered
Pennsylvania Covered Covered Not Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Partial Coverage
South Dakota Covered Covered Not Covered
Tennessee* - - -
Texas Covered Covered Not Covered
Utah Partial Coverage, PA Required Covered Covered
Vermont Covered Covered Covered
Virginia Not Covered Partial Coverage Partial Coverage, PA Required
Washington Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
West Virginia Covered Covered, PA Required Not Covered
Wisconsin Covered Covered Covered, PA Required
Wyoming Not Covered Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-44 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Prior Authorization (Con’t)


Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered, PA Required Covered Covered
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered, PA Required Partial Coverage Partial Coverage
California Covered, Some PA Required Covered, Some PA Required Covered, Some PA Required
Colorado Covered Covered Partial Coverage, Under 21
Connecticut Covered Covered Covered
Delaware Covered Covered Covered
District of Columbia N/A N/A N/A
Florida Covered Covered Not Covered
Georgia Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Hawaii Covered, PA Required Covered, PA Required Covered
Idaho Covered Covered Covered
Illinois N/A N/A N/A
Indiana N/A N/A N/A
Iowa Covered, PA Required Covered Covered
Kansas Covered Partial Coverage, PA Required Covered
Kentucky Covered, PA Required Covered, Some PA Required Covered, Some PA Required
Louisiana Covered Covered Not Covered
Maine Covered Covered Not Covered
Maryland Covered Covered Covered
Massachusetts Covered Covered, PA for prolonged use Covered, PA Required
Michigan Covered Covered Not Covered
Minnesota Covered Covered Covered
Mississippi Covered Covered Not Covered
Missouri Covered Partial Coverage, PA Required Covered
Montana Covered Covered, PA Required Covered
Nebraska Covered Covered Covered
Nevada Covered Covered Covered, PA Required
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered Covered Partial Coverage, PA Required
North Carolina Covered Covered Covered
North Dakota Covered Covered Partial Coverage
Ohio Covered Covered Covered
Oklahoma Covered, PA Required Covered, PA Required Not Covered
Oregon Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Partial Coverage
Rhode Island N/A N/A N/A
South Carolina Covered Covered Covered
South Dakota Covered Covered Covered
Tennessee* N/A N/A N/A
Texas Covered Covered Covered
Utah Covered Covered Covered
Vermont Covered Covered Covered
Virginia Partial Coverage Covered Partial Coverage
Washington Covered, PA Required Covered, PA Required Covered, PA Required
West Virginia Covered Partial Coverage Partial Coverage
Wisconsin Partial Coverage Covered Partial Coverage
Wyoming Covered Covered Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-45


Pharmaceutical Benefits 2000

Prior Authorization (Con’t)


Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered, PA Required Covered Not Covered
Alaska Covered, PA Required Covered Not Covered
Arizona* N/A N/A N/A
Arkansas Covered Covered, PA Required Covered, PA Required
California Covered, PA Required Covered, Some PA Required Covered, Some PA Required
Colorado Covered, PA Required Covered Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Covered, PA Required Covered Covered
District of Columbia N/A N/A N/A
Florida Covered, PA Required Covered Covered
Georgia Covered, PA Required Covered Not Covered
Hawaii Covered, PA Required Covered, PA Required Covered, PA Required
Idaho Covered, PA Required Covered Not Covered
Illinois N/A N/A N/A
Indiana N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Not Covered
Kansas Covered, PA Required Covered Covered
Kentucky Covered Covered Not Covered
Louisiana Covered Covered Covered
Maine Covered, PA Required Covered Covered
Maryland Covered, PA Required Covered Covered
Massachusetts Covered Covered, PA for prolonged use Not Covered
Michigan Covered, PA Required Covered Covered, PA Required
Minnesota Covered Covered, PA Required Covered
Mississippi Covered, PA Required Covered Not Covered
Missouri Not Covered Covered Not Covered
Montana Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Nebraska Covered, PA Required Covered Not Covered
Nevada Covered, PA Required Covered Covered
New Hampshire Covered Covered Covered
New Jersey Partial Coverage Covered Partial Coverage
New Mexico Covered Covered Covered
New York Covered Partial Coverage, PA Required Covered
North Carolina Covered Covered Covered
North Dakota N/A Covered Covered, PA Required
Ohio Covered, PA Required Covered Covered
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Not Covered
Rhode Island N/A N/A N/A
South Carolina Covered Covered Partial Coverage
South Dakota Covered PA Required Covered Not Covered
Tennessee* N/A N/A N/A
Texas Covered Covered Covered
Utah Partial Coverage, PA Required Covered Not Covered
Vermont Covered Covered Covered, PA Required
Virginia Covered Covered Covered
Washington Partial Coverage, PA Required Covered, PA Required Not Covered
West Virginia Covered, PA Required Covered, PA Required Covered, PA Required
Wisconsin Covered PA Required Covered, PA Required Covered, PA Required
Wyoming Covered Covered Not Covered

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization
Source: As reported by state drug program administrators in the 2000 NPC Survey.

4-46 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Drug Utilization Review


PRODUR
State State Contact Telephone In-House or Contracted Implemented
Alabama Louise Jones 334-242-5039 Contracted Jul-96
Alaska Dave Campana, R.Ph. 907-273-3224 In-House and Contracted Jun-95
Arizona* - - - -
Arkansas Suzette Bridges, P.D. 501-324-9141 Contracted Mar-97
California Vic Walker, R.Ph., B.C.P.P. 916-657-0785 In-House Aug-95
Colorado Allen Chapman 303-866-3176 Contracted Dec-98
Connecticut Elizabeth Geary, R.Ph. 860-424-5150 Contracted Sep-96
Delaware Cynthia Denemark 302-453-8453 Contracted Feb-94
District of Columbia Christopher Keeyes, Pharm.D. 301-572-1616 In-House No
Florida Marie Donnelly-Stephens 850-487-4441 Contracted Jul-95
Georgia Jean B. Cox, R.Ph. 404-657-7241 In-House Planned for 2000
Hawaii Kathleen Kang-Kaulupali 808-692-8115 In-House N/A
Idaho Gary Duerr, R.Ph. 208-364-1829 Contracted Jan-98
Illinois N/A N/A In-House Jan-93
Indiana Karen Baer 317-232-4391 Contracted Mar-96
Iowa Cheryl Clarke, R.Ph. 515-270-0713 Contracted Jul-97
Kansas Glenn McNees, R.Ph., M.S. 785-864-3164 Contracted Nov-96
Kentucky Debra Bahr 502-564-6511 Contracted Sep-94
Louisiana Melwyn Wendt 504-219-4154 Contracted Apr-96
Maine Timothy Clifford, M.D. 207-287-2674 Contracted Dec-95
Maryland Judy Geisler 410-767-1728 Contracted Jan-93
Massachusetts Anna Morin 508-721-7104 Contracted Oct-95
Michigan Mary Sandusky 517-335-5280 Contracted Jul-00
Minnesota MaryBeth Reinke, Pharm.D. 651-215-1239 In-House Feb-96
Mississippi James G. "Jack" Lee, R.Ph. 601-359-6296 Contracted Oct-95
Missouri Jayne Zemmer 573-751-6963 Contracted Feb-93
Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94
Nebraska Allison Jorgensen, Pharm.D., R.Ph. 402-420-1500 Contracted Apr-95
Nevada Laurie Squartsoff, R.Ph. 702-687-4869 Contracted Planned for 2001
New Hampshire Lisè Farrand 603-271-4419 Contracted Aug-95
New Jersey Edward Vaccaro, R.Ph. 609-588-2721 In-House Oct-96
New Mexico Chuck Reynolds 505-827-3174 Contracted Oct-93
New York Michael Zegarelli 518-474-0691 In-House Mar-95
North Carolina Sharman Leinwand 919-733-3590 In-House Oct-96
North Dakota Pat Kramer 701-328-4893 In-House Jul-96
Ohio Jan Lawson 614-466-7936 Contracted Feb-00
Oklahoma John Crumly, M.H.A., R.Ph. 405-522-7300 Contracted Mar-93
Oregon Mariellen Rich 503-391-1980 Contracted Mar-94
Pennsylvania N/A - In-House Jun-93
Rhode Island Paula Avarista 401-464-2183 Contracted Dec-94
South Carolina Caroline Sojourner 803-898-2876 In-House and Contracted No
South Dakota Michael Jockheck 605-773-6439 In-House Planned for 2000
Tennessee* - - - -
Texas Curtis Burch 512-338-6922 In-House Feb-95
Utah Duane Parke 801-538-6452 In-House Jun-95
Vermont Gloria Jacobs 802-241-2763 Contracted Nov-93
Virginia Marianne Rollins, R.Ph. 804-225-4268 Contracted Jul-94
Washington Siri Childs 360-725-1564 In-House Mar-96
West Virginia Peggy A. King, R.Ph. 304-588-1753 Contracted Mar-95
Wisconsin Dr. Michael Mergener 608-258-3348 Contracted Planned for 2001
Wyoming Debra Devereuax, R.Ph. 307-766-6120 Contracted Oct-95

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PRODUR = Prospective Drug Utilization Review System
Source: As reported by state drug program administrators in the 2000 NPC Survey.

National Pharmaceutical Council 4-47


Pharmaceutical Benefits 2000

Prescribing/Dispensing Limits
Limits on
State Prescriptions Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx
Alaska Yes 30 day supply per Rx
Arizona* - -
Arkansas Yes 30 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month without PA, other limitations specific to certain medications
Colorado No 100 day supply for maintenance medication
Connecticut No -
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds
Florida Yes Variable 6/8/10/12 Rxs per month (with exceptions); Max/min quantities for certain meds
Georgia Yes 30 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $1000/Rx
Hawaii Yes 30 day supply or 100 unit doses per Rx
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control
Illinois Yes Medically appropriate monthly quantity; 11 refills per Rx
Indiana No -
Iowa No -
Kansas Yes 34 day supply per Rx, other limitations specific to certain medications
Kentucky Yes Maximum 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 months
Maine No -
Maryland Yes 34 day supply per Rx; 2 refills per Rx
Massachusetts Yes 5 refills within 6 months per Rx
Michigan Yes No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days
Minnesota Yes 30 day supply for maintenance drugs; max 3 month supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum
Missouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximum
Montana Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
Nebraska Yes 3 month supply maximum, 5 refills per Rx within 6 months for controlled substances
Nevada Yes 34 day supply per Rx; 3 Rx per month
New Hampshire Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
New Jersey Yes 34 day supply or 100 unit doses per Rx
New Mexico No 6 months supply maximum
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 100 day supply per Rx; 6 Rx per month
North Dakota Yes 34 day supply per Rx
Ohio Yes Consistent with State/Federal requirements
Oklahoma Yes 3 Rx per month (21+; under 21 unlimited)
Oregon Yes 34 day supply per Rx
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 months
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 100 day supply w/ unlimited Rx (children); 4 Rx per month
South Dakota No -
Tennessee* - -
Texas Yes 3 Rx per month with exceptions; unlimited Rxs for nursing home recipients or those < 21
Utah Yes Monthly quantity limit, maximum varies per person
Vermont No -
Virginia No -
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 10 Rx per month; 5 refills per Rx
Wisconsin No 34 day supply per Rx
Wyoming Yes 90 day supply for maintenance drugs and birth control, 34 day supply for all others

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

PHARMACY PAYMENT AND PATIENT COST SHARING


Federal Medicaid regulations dictate the method for reimbursing prescription drugs. Reimbursement is made on a
retrospective, fee-for-service basis, with payments limited to the lower of:

• The estimated acquisition cost (EAC) of the drug (the price generally and currently paid by providers for
a particular drug in the package size most frequently purchased by providers), as determined by the
program agency, plus a reasonable dispensing fee; or
• The providers’ usual and customary charge to the public for the drug.
Regulations require states to submit a state plan that describes their payment methods for prescribed drugs. The
regulations do not prescribe a preferred payment method, but states are required to submit assurances to HCFA
that the requirements are met.

The Health Care Financing Administration’s (HCFA) publishes a list of multiple-source drugs (generic drugs) to
which the upper limit payment formula applies (commonly referred to as the Federal Upper Limit List).
Revisions to the list are provided periodically through Medicaid program issuances under the title “State Medicaid
Manual - Part 6, Payment for Services.” Any price revisions are included in these issuances. The current version
of this list is included as Appendix D: Specific Upper Limits for Multiple Source and “Other” Drugs. The
formula does not apply to any prescription for which the prescriber certified in his or her own handwriting that a
certain brand of drug is “medically necessary” for the patient.

According to the regulations, as long as the state’s aggregate spending is at or below the amount derived from the
formula, the state is free to maintain its current payment program or adopt other methods. States can alter
payment rates for individual drugs, balancing payment increases for certain products with payment decreases for
other drugs so that, in the aggregate, the program does not exceed the established limit. State programs
implemented to comply with these requirements are frequently referred to as Maximum Allowable Cost (MAC)
programs.

PATIENT COST SHARING

States are permitted to require certain recipients to share some of the costs of Medicaid by imposing on them such
payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost-sharing charges
(42 CFR 447.50). For states that impose cost-sharing payments, the regulations specify the standards and
conditions under which states may impose cost-sharing, set forth minimum amounts and the methods for
determining maximum amounts, and describe limitations on availability that relate to cost-sharing requirements.

With the passage of the Social Security Amendments of 1972, states were empowered to impose “nominal” cost-
sharing requirements on optional Medicaid services for cash assistance recipients, and on any services for the
medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introduced
major changes to Medicaid cost-sharing requirements. Under this act, states may impose a nominal deductible,
coinsurance, copayment, or similar charge on both categorically needy and medically needy persons for any
service offered under the state plan. Public Law 97-248, TEFRA, has been in effect since October 1982; it
prohibits imposition of cost-sharing on the following:

• Services furnished to individuals under 18 years of age (or up to 21 at state option);


• Pregnancy-related services (or, at state option, any service provided to pregnant women);
• Services provided to certain institutionalized individuals, who are required to spend all of their income for
medical care except for a personal needs allowance;
• Emergency services;

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Pharmaceutical Benefits 2000

• Family planning services and supplies;


• Services furnished to categorically needy HMO enrollees (or, at state option, services provided to both
categorically needy and medically needy HMO enrollees).
In addition, the law prohibits imposing more than one type of charge on any service.

While emergency services are excluded from cost sharing, states may apply for waivers of nominal amounts for
non-emergency services furnished in hospital emergency rooms. Such a waiver allows states to impose a
copayment amount up to twice the current maximum for such services. Approval of a waiver request by HCFA is
based partly on the state’s assurance that recipients will have access to alternative sources of care.

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Pharmaceutical Benefits 2000

Pharmacy Payment and Patient Cost Sharing


State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45 AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 AWP-10.5% $0.50 - $3.00
California $4.05 AWP-5% G: $1.00, B: $1.00
Colorado $4.08 AWP-10% or WAC+18%, whichever is lowest G: $0.50, B: $2.00
Connecticut $4.10 AWP-12% None
Delaware $3.65 AWP-12.9% None
District of Columbia $3.75 AWP-10% $1.00
Florida $4.23 AWP-13.25% None
Georgia $4.63 AWP-10% $0.50
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-11% None
Illinois G: $3.75, B: $3.45 AWP-10%, AWP-12% for multi-source drugs None
Indiana $4.00 AWP-10% $0.50 - $3.00
Iowa $4.13 - $6.42 AWP-10% $1.00
Kansas $4.50 AWP-10% $2.00
Kentucky OP: $4.75, LTC: $5.75 AWP-10% None
Louisiana $5.77 AWP-10.5% $0.50 - $3.00
Maine $3.35 (+ extra fees for compounding) AWP-10% $0.50 - $3.00
Maryland $4.21 Lowest of :WAC + 10%, direct + 10%, AWP -10% $1.00
Massachusetts $3.00 WAC+10% $0.50
Michigan $3.72 AWP-13.5% (1 to 4 stores), AWP-15.1% (5+ stores) $1.00
Minnesota $3.65 AWP-9% None
Mississippi $4.91 AWP-10% $1.00
Missouri $4.09 AWP-10.43% $0.50 - $2.00
Montana $2.00 - $4.20 AWP-10% G: $1.00, B: $2.00
Nebraska $3.20 - $5.05 AWP-8.71% $1.00
Nevada $4.76 AWP-10% None
New Hampshire $2.50 AWP-12% G: $0.50, B: $1.00
New Jersey $3.73 - $4.07 AWP-10% None
New Mexico $4.00 AWP-12.5% None
New York B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00
North Carolina $5.60 AWP-10% $1.00
North Dakota $4.60 AWP-10% None
Ohio $3.70 AWP-11% None
Oklahoma $4.15 AWP-10.5% $1.00 - $2.00
Oregon $3.91-$4.28 (based on annual # of Rx) AWP-11% None
Pennsylvania $4.00 AWP-10% $1.00 - $2.00
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $2.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* - - -
Texas $5.27 + 2% of ingredient & dispensing fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 - $4.40 (based on geographic area) AWP-12% $1.00 - $5.00
Vermont $4.25 AWP-11.9% $1.00 - $2.00
Virginia $4.25 AWP-9% $1.00
Washington $4.06 - $5.02 (based on annual # of Rx) AWP-11% None
West Virginia $3.90 (+ extra fees for compounding) AWP-12% $0.50 - $2.00
Wisconsin $4.88 AWP-10% $0.50 - $1.00
Wyoming $4.70 AWP-4% $2.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Maximum Allowable Cost (MAC) Programs


Federal Upper State-Specific
State Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason for medical necessity
Arizona* Yes No Brand necessary
Arkansas Yes Yes Brand medically necessary
California Yes Yes Medically necessary and other products unavailable at MAC rate
Colorado Yes Yes Prior authorization
Connecticut Yes No Brand medically necessary
Delaware Yes Yes Brand medically necessary
District of Columbia Yes No Brand medically necessary
Florida Yes Yes If drug is on Florida Negative Formulary
Georgia Yes Yes Brand medically necessary
Hawaii Yes No Brand necessary, prior authorization
Idaho Yes Yes Brand medically necessary, handwritten by M.D., prior authorization
Illinois Yes Yes Prior authorization request by M.D. or R.Ph
Indiana Yes No Brand medically necessary
Iowa Yes No Brand medically necessary
Kansas Yes Yes Brand medically necessary, prior authorization
Kentucky Yes No Brand necessary, brand medically necessary
Louisiana Yes No Brand necessary or brand medically necessary
Maine Yes No Dispense as written
Maryland Yes Yes Brand medically necessary and reason for medical necessity
Massachusetts Yes No Dispense as written, brand medically necessary
Michigan Yes Yes Prior authorization
Minnesota Yes Yes Brand medically necessary
Mississippi Yes No Brand medically necessary
Missouri Yes Yes Prior authorization
Montana Yes No Dispense as written, brand necessary
Nebraska Yes Yes Brand medically necessary and MC-6 form signed by M.D.
Nevada Yes No Brand medically necessary
New Hampshire Yes No Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes No Brand medically necessary
New York Yes No Dispense as written and brand necessary, or brand medically necessary
North Carolina Yes No Brand medically necessary
North Dakota Yes No Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary
Oregon Yes No Brand necessary, medically necessary, or brand medically necessary
Pennsylvania Yes Yes Brand necessary or brand medically necessary, plus prior authorization
Rhode Island Yes No Dispense as written, brand medically necessary
South Carolina Yes Yes Brand necessary or brand medically necessary
South Dakota Yes No Brand medically necessary
Tennessee* - - -
Texas Yes Yes Brand necessary or brand medically necessary
Utah Yes No Dispense as written, brand medically necessary, or medical necessary
Vermont Yes No Dispense as written
Virginia Yes Yes Brand necessary
Washington No Yes Brand medically necessary
West Virginia Yes No Brand medically necessary
Wisconsin No Yes Brand medically necessary
Wyoming No No -

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Mandatory Substitution
Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost
State Generic Substitution Multisource Required Multisource Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas No Yes No
California No No Yes
Colorado No Yes (if FUL or State MAC) No
Connecticut $0.50 No No
Delaware No Yes No
District of Columbia No No Yes
Florida No Yes No
Georgia No Yes (brand PA required) Yes
Hawaii No Yes (if FUL) No
Idaho No Yes No
Illinois No No No
Indiana No Yes No
Iowa No Yes No
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland No No (payment based on generic) No
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No No No
Missouri No No No
Montana No No No
Nebraska No No No
Nevada No Yes Yes
New Hampshire No Yes Yes
New Jersey No Yes No
New Mexico No Yes Yes
New York Yes Yes (if M.D. allows substitution) No
North Carolina No Yes No
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes (if M.D. authorizes) Yes
South Dakota No No No
Tennessee* - - -
Texas No Yes No
Utah No Yes No
Vermont No Yes No
Virginia No No No
Washington No No (except MAC drug, 3+ labelers) No
West Virginia No Yes No
Wisconsin No No No
Wyoming No No No

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Counseling Requirements and Payment for Cognitive Services


Medicaid Payment
State Patient CounselingRequired1 for Cognitive Services2
Alabama All No
Alaska All No
Arizona All -
Arkansas All No
California All No
Colorado Medicaid Only No
Connecticut Medicaid Only No
Delaware All No
District of Columbia Pending No
Florida All No
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All No
Kansas All No
Kentucky All No
Louisiana All No
Maine All Yes
Maryland Medicaid Only No
Massachusetts All No
Michigan All No
Minnesota Medicaid Only No
Mississippi All No
Missouri All No
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All No
New Mexico All No
New York All No
North Carolina All No
North Dakota All No
Ohio All No
Oklahoma All No
Oregon All No
Pennsylvania All No
Rhode Island All No
South Carolina Medicaid Only No
South Dakota All No
Tennessee All -
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All No
West Virginia All No
Wisconsin All Yes
Wyoming All No

Source: 12000-2001 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2As reported by state drug program
administrators in the 2000 NPC Survey.

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Prescription Price Updating


State Contact Telephone Updated
Alabama First DataBank 650-588-5454 Biweekly
Alaska Dave Campana 907-273-3224 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California Electronic Data Systems 916-636-1000 Monthly
Colorado Allen Chapman 303-866-3176 Weekly
Connecticut First DataBank 650-588-5454 Weekly
Delaware Cynthia Denemark 302-453-8453 Bimonthly
District of Columbia First DataBank 650-588-5454 Monthly
Florida First DataBank 650-588-5454 Weekly
Georgia Etta Hawkins 404-657-7239 Monthly
Hawaii First DataBank 800-633-3453 Monthly
Idaho Gary Duerr 208-334-5795 Bimonthly
Illinois First DataBank 650-588-5454 Weekly
Indiana First DataBank 317-469-5200 Monthly
Iowa Sherry Swanson 515-327-0950 Weekly
Kansas Karen Bramen 785-296-6968 Weekly
Kentucky Unisys 502-226-1140 Bimonthly
Louisiana Maggie Vick, Unisys Corp. 504-237-3251 Weekly
Maine Susan Curtis 207-287-1818 Bimonthly
Maryland First DataBank 650-588-5454 Weekly
Massachusetts Christopher Burke 617-210-5592 Weekly
Michigan First DataBank 650-588-5454 Weekly
Minnesota First DataBank 650-588-5454 Bimonthly
Mississippi James G. Lee 601-359-6296 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska First DataBank 650-588-5454 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire First DataBank 650-588-5454 Biweekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Chuck Reynolds 505-827-3174 Weekly
New York Carl Cioppa, Pharm.D.. 518-486-3209 Monthly
North Carolina Benny Ridout 919-857-4034 Weekly
North Dakota First DataBank 800-633-3453 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma Angela Thomasson 405-522-7307 Weekly
Oregon Kathy Franklin, First DataBank 650-588-5454 Bimonthly
Pennsylvania First DataBank 800-633-3453 Monthly
Rhode Island Paula Avarista 401-464-2183 Biweekly
South Carolina First DataBank 650-588-5454 Monthly
South Dakota Mark Petersen 605-773-3498 Bimonthly
Tennessee* - - -
Texas Martha McNeill 512-338-6965 Continuously
Utah RaeDell Ashley 801-538-6495 Bimonthly
Vermont Christine Dapkiewicz 802-879-4450 Biweekly
Virginia David Shepherd 804-786-8057 Monthly
Washington Marilyn Mueller 360-725-1569 Weekly
West Virginia Leslie Bratton 800-358-2381 Weekly
Wisconsin First DataBank 800-633-3453 Bimonthly
Wyoming First DataBank 800-633-3453 Weekly

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by state drug program administrators in the 2000 NPC Survey.

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Pharmaceutical Benefits 2000

Section 5:
State
Pharmacy Assistance
Programs

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Pharmaceutical Benefits 2000

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Pharmaceutical Benefits 2000

State Pharmacy Assistance Programs


As of the end of December 2000, 26 states had authorized some type of program to provide pharmaceutical
coverage or assistance to low-income elderly and/or persons with disabilities who do not qualify for Medicaid.
These programs range from providing access to state-negotiated discounts to state subsidies and tax credits for
prescription drug expenditures. These programs currently provide assistance to over 850,000 individuals, and an
estimated 1.5 million more individuals are eligible for assistance.

Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted


California Discount Prescription Medication Program 1999
Connecticut Pharmaceutical Assistance Contract to the Elderly and
Connecticut 1985
the Disabled Program (ConnPACE)
Nemours Pharmacy Assistance 1981
Delaware
Delaware Prescription Drug Assistance Program (DPAP) 1999
Florida Pharmaceutical Expense Assistance Program 2000
Illinois Pharmaceutical Assistance Program (PAP) 1985
Indiana Indiana Prescription Drug Fund -- HoosierRx 2000
Iowa Pharmaceutical Discount Program †‡
Kansas Senior Pharmacy Assistance Program 2000†
Low Cost Drugs for the Elderly Program 1975
Maine
Maine Rx Program 2000†
Maryland Pharmacy Assistance Program 1979
Maryland
Short-Term Prescription Drug Subsidy Plan 2000
The Pharmacy Program 1996
Massachusetts Pharmacy Program Plus 1999
Subsidized Catastrophic Prescription Drug Insurance Program 2000†
Michigan Emergency Pharmaceutical Program for Seniors (MEPPS) 1988
Michigan
State Medical Plan 1988
Minnesota Senior Citizen Drug Program 1997
Missouri State Income Tax Credit for Legend Drugs 1999
New Hampshire New Hampshire Senior Prescription Drug Discount Program ‡
New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD) 1975
New York Elderly Pharmaceutical Insurance Coverage (EPIC) 1987
Nevada Subsidy Program 1999
North Carolina Prescription Drug Assistance Program 1999
Pharmaceutical Assistance Contract for the Elderly (PACE) 1984
Pennsylvania
PACE Needs Enhancement Tier (PACENET) 1996
Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) 1985
South Carolina SilverCard Program 2000
VSCRIPT 1989
Vermont Vermont Health Access Program (VHAP) 1996
Pharmacy Discount Program (PDP) 2000
A Washington Alliance to Reduce Prescription-Drug Spending
Washington ‡
(AWARDS)
West Virginia Senior Prescription Assistance Network II (SPAN II) ‡
Wyoming Minimum Medical Program 1988
†Program not yet operational.
‡Not written into law. Program is either in pilot phase or under executive orders.

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Nine states (Florida, Iowa, Kansas, Maine, Massachusetts, Nevada, South Carolina, Vermont, and Washington)
have plans for new programs that are expected to commence in the year 2001 or later.

• Florida’s Pharmaceutical Expense Assistance Program: Florida’s program is designed to provide a


subsidy, limited to $80 per month, to individuals over 65 who are dually-eligible for Medicaid and Medicare
but do not have pharmaceutical coverage. Participants will be required to pay a 10% coinsurance payment
for each prescription. An estimated 30,000 individuals are eligible for this program. This program went into
effect on January 1, 2001.

• Iowa’s Pharmaceutical Discount Program: Iowa legislators have acquired federal funds to establish a
demonstration project to lower pharmaceutical costs for individuals and other purchasers through the
establishment of a prescription drug purchasing co-op. Individuals as well as local pharmacies would be
eligible to join the co-op with additional participants eligible including employers, the self-employed,
insurers and others. Participants would be required to a minimal fee to join the co-op. The State of Iowa
would either directly or through a private sector contractor negotiate volume-purchasing discounts with drug
manufacturers. Members of the co-op would then pay the discounted rate when they purchase their
medications. This project is scheduled to go into effect on July 1, 2001.

• Kansas’ Senior Pharmacy Assistance Program: This new law (HB 2814), signed into law in May 2000, is
designed to provide direct subsidies to low-income seniors for the purchase of prescription drugs. The
minimum age for eligibility will be 67 years of age, and the income eligibility level will be 150% of the
federal poverty level. This program is scheduled to go into effect on July 1, 2001.

• Maine Rx Program: The Rx Program was created to provide a discounted price on prescription drugs for any
eligible resident who enrolls in the program. The law, which created the new program, also provides
authorization for the Commissioner of Human Services to establish maximum retail prices effective July
2003 “if prices paid under the Maine Rx program for the most common drugs are not reasonably comparable
to the lowest prices paid in the state.” The program is scheduled to commence on April 1, 2001.

• Massachusetts’s Subsidized Catastrophic Prescription Drug Insurance Program. Planned to replace the
two programs currently in effect in Massachusetts, this new program will offer benefits to individuals 65
years of age or older, or individuals under age 65 who work less than 40 hours per month and meet the
disability guidelines for CommonHealth. There will be no income eligibility requirement; however, monthly
premiums, deductibles, and copay will be based on income. This new program is scheduled to go into effect
on April 1, 2001.

• Nevada’s Subsidy Program: Nevada’s SenioRx is a prescription insurance subsidy program that began on
January 1, 2001. The program is comprised of two plans: the Basic Plan and the Enhanced Plan, with
monthly premiums of $74.76 and $98.31 respectively, the latter covering some brand name drugs. Both
include a $100 yearly deductible, a $10 copayment for generic drugs, and a $5,000 maximum yearly benefit.
Seniors with annual income of $12,700 or less would be eligible for a $40 monthly subsidy; seniors with
income up to $21,500 would be eligible for less. The state will pay a maximum of $480 per year toward the
cost of the policy. The minimum age is 62. The program will be funded by the tobacco settlement.

• South Carolina’s SilverxCard Program: South Carolina’s new program went into effect on January 1, 2001.
This program offers assistance to those who are 65 years or older, have income below 175% of the federal
poverty level ($14,612 for single; $19,678 for married), and have been South Carolina residents for 6 months.
Total program funding for 2001 is estimated to be $20 million from the state’s tobacco settlement. Senior
citizens enrolled in the SilverxCard program are not eligible for Medicaid and may not have other
prescription insurance coverage.

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• Vermont’s Pharmacy Discount Program: The Pharmacy Discount Program is an expansion of the current
Vermont Health Access Program. Under the new program, eligibility is expanded to include any Medicare-
covered individual with income above 150% of federal poverty level without drug coverage and all
individuals with incomes up to 300% federal poverty level who do not have a benefit program that includes
drug coverage. Beneficiaries have the ability to purchase drugs at a price that is equivalent to the price that is
available to the Medicaid program. Approximately 69,000 individuals are eligible for this program which
began on January 1, 2001.

• A Washington Alliance to Reduce Prescription-Drug Spending: The AWARDS program, in operation since
January 15, 2001, will offer Washington residents aged 55 and older significantly lower prescription drug
costs. Eligible beneficiaries will pay an annual fee of $15 per individual or $25 per family to join what will
be considered a “buyer's club.” Through combined agency purchasing power, beneficiaries can expect to
save anywhere from 12 percent to 30 percent of retail price for prescriptions.

The following pages provide profiles of 20 states that provided pharmacy assistance in 2000. Details were
provided by state contacts on program characteristics, including eligibility criteria, funding and reimbursement
information, and drug coverage.

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California
Discount Prescription Medication Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Eligibles (FY 00): 1,300,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Anyone who has a Medicare card is eligible

FUNDING AND REIMBURSEMENT

Funding Source: No funding, program offers state-negotiated discounts


Budget (FY 00): N/A
Cost per Participant (FY 00): N/A
# of Rx’s Per Participant (FY 00): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $0.15 per prescription
Notes: All enrollees are eligible for discounts on prescriptions

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All prescription drugs
Drug Coverage Restrictions: No formulary restrictions and no prior authorization
Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program must
also allow Medicare recipients to purchase drugs for the same price
paid by Medi-Cal. Pharmacies must participate in this program in
order to participate in the Medi-Cal program.

PROGRAM CONTACT

Department of Health Services Phone: 916/657-4213


714 P Street, Room 1253
Sacramento, CA 95814

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Pharmaceutical Benefits 2000

Connecticut
ConnPACE
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (FY 00): 31,666
(Elderly: 27,434; Disabled: 4,232)

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $14,700 Eligible Income Level (Married): $17,700
Other Eligibility Notes: None

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund


Budget (FY 00): $39.6 million
Cost per Participant (FY 00): $1,357.62
# of Rx’s Per Participant (FY 00): 22.44
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 12%
Enrollment Fee: $25.00/annual
Deductible Amount: None
Copayment Amount: $12.00/Rx
Dispensing Fee: $4.10

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All prescription drugs and insulin, 120 unit or 30 day supply limit,
whichever is greater
Drug Coverage Restrictions: Restrictions on antihistamines, cough preparations, cosmetic, diet and
fertility/contraceptive drugs. Also restricted are multivitamins,
smoking cessation gum and DESI drugs.
Prescription Drug Utilization: $39,417,855 program spending, 651,585 scripts
Notes: ConnPACE pays the difference between the copayment paid by the
enrollee and the cost of the drug.

PROGRAM CONTACT

Elizabeth A. Geary, R.Ph. Phone: 860/424-5150


Department of Social Services Fax: 860/951-9544
25 Siqourney Street E-mail: elizabeth.geary@po.state.ct.us
Hartford, CT 06106

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Pharmaceutical Benefits 2000

Delaware
Nemours Pharmacy Assistance
Program Type: Private Discount Program
Year Operational: 1981
Number of Recipients (FY 00): 26,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


Eligible Income Level (Single): $12,500 Eligible Income Level (Married): $17,125
Other Eligibility Notes: U.S. Citizen, Resident of Delaware

FUNDING AND REIMBURSEMENT

Funding Source: Nemours Foundation (Program receives no state or federal funds)


Budget: N/A
Cost per Participant (FY 99): $622.63
# of Rx’s Per Participant (FY 99): 19.69
Manufacturer Rebate Type: None
Ingredient Cost Calculation: None
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 20% of drug cost
Dispensing Fee: None
Notes: Maximum yearly benefit: $2,000 based on average retail cost

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: Prescription drugs, insulin syringes, and prescribed OTCs
Drug Coverage Restrictions: Injectables, except for insulin
Prescription Drug Utilization: Program spending, volume of scripts unknown
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply. Formulary
limited due to budgetary restraints.

PROGRAM CONTACT

W. Frank Morris, Jr. Phone: 302/651-4405


Nemours Clinic Pharmacy Assistance Fax: 302/651-4445
1801 Rockland Road E-mail: fmorris@nemours.org
Wilmington, DE 19803

5-8 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Delaware
Prescription Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 2,203
(Elderly: 986; Disabled: 1,217)

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 21+


Eligible Income Level (Single): $16,480 Eligible Income Level (Married): $22,120
Other Eligibility Notes: Senior citizens eligible for the Nemours program are not eligible for
this program. Elderly and SSDI individuals who have income over
these amounts may also be eligible if they have drug costs that are
over 40% of their yearly income.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco settlement (not subject to budget appropriation)


Budget: $7.5 million
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 12.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Greater of $5 or 25% AAC
Dispensing Fee: $2.65

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: Similar to Medicaid but limited by state rebate participation
Drug Coverage Restrictions: Annual limit of $2,500 per person
Prescription Drug Utilization: N/A
Notes: None

PROGRAM CONTACT

Cynthia Denemark Phone: 302/453-8453 ext. 211


Division of Social Services Fax: 302/454-7603
248 Chapman Road Suite 200 E-mail: cynthia.denemark@eds.com
Newark, DE 19702

National Pharmaceutical Council 5-9


Pharmaceutical Benefits 2000

Illinois
Pharmaceutical Assistance Program (PAP)
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (FY 00): 53,555

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+


Eligible Income Level (Single): $21,218 Eligible Income Level (Married): $28,480
Other Eligibility Notes: Widow(er) who turned 63 or 64 before deceased claimant’s death is
eligible

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund (subject to budget appropriations)


Budget: $35 million
Cost per Participant (FY 99): $207.84 annually
# of Rx’s Per Participant (FY 99): 24.58
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10% or MAC if generic is available
Enrollment Fee: $5 if below FPL, $25 if above FPL
Deductible Amount: None
Copayment Amount: No copayment if below FPL, then 20% of drug cost after program
pays $2,000 in a fiscal year.
$3.00 copayment if above FPL, then 20% of drug cost after program
pays $2,000 in a fiscal year.
Dispensing Fee: None

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,
Parkinson’s disease, glaucoma, lung disease and smoking-related
diseases.
Drug Coverage Restrictions:
Notes:

PROGRAM CONTACT

Sue Coombe Phone: 217/785-5905


Illinois Department of Revenue Fax: 217/524-9213
P.O. Box 19021 E-mail: scoombe@revenue.state.il.us
Springfield, IL 62794-9021

5-10 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Indiana
Prescription Drug Fund “HoosierRx”
Program Type: Refunds
Year Operational: 2000
Estimated Eligibles (FY 00): 66,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): $11,280 Eligible Income Level (Married): $15,192
Other Eligibility Notes: None

FUNDING AND REIMBURSEMENT

Funding Source: National Tobacco Fund


Budget: $20 million
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: None
Notes: Refunds based on monthly income.

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: FDA-approved prescription drugs and insulin
Drug Coverage Restrictions: Maximum benefit of $1,000 per year
Notes: Refund amount is limited to 50% of actual out-of-pocket expenses, up to
the maximum benefit, based on monthly income:
Single Married Refund
$940 or less $1,266 or less 50% refund up to $500 per year
$835 or less $1,125 or less 50% refund up to $750 per year
$696 or less $938 or less 50% refund up to $1,000 per year

PROGRAM CONTACT

Grace Chandler Phone: 866/267-4679


HoosierRx
P.O. Box 6224
Indianapolis, IN 46206-6224

National Pharmaceutical Council 5-11


Pharmaceutical Benefits 2000

Maine
Low Cost Drugs for the Elderly and Disabled Program
Program Type: Direct Assistance
Year Operational: 1975
Number of Recipients (FY 99): 24,900

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 55+


Eligible Income Level (Single): $15,348 Eligible Income Level (Married): $20,461
Other Eligibility Notes: If 40% of income goes to drugs the eligible incomes increase to
$19,185 for Single and $25,575 for Married.

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund


Budget: $7.6 million
Cost per Participant (FY 99): $154.55
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Greater of $2 or 20% of drug cost
Dispensing Fee: $3.35

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All drugs from participating manufacturers used for the chronic
treatment of diabetes, asthma, COPD, cardiac conditions, arthritis
Drug Coverage Restrictions: N/A
Notes:

PROGRAM CONTACT

Christine Gee Phone: 207/287-4018


Department of Human Services Fax: 207/287-8601
11 State House Station
August, ME 04333-0011

5-12 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Maryland
Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Number of Recipients (FY 00): 34,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): $9,650 Eligible Income Level (Married): $10,450
Other Eligibility Notes: No age restriction on eligibility

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund (subject to budget appropriations)


Budget: $37.3 million
Cost per Participant (FY 99): $1,124
# of Rx’s Per Participant (FY 99): 24.09
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: WAC + 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00
Dispensing Fee: $3.73 - $4.07

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: Specified categories of maintenance drugs used to treat chronic
conditions, anti-infective drugs, and insulin syringes and needles
Drug Coverage Restrictions: 75% utilization required before prescription refill
Notes: The following groups are ineligible for participation: people detained
in a correctional (federal, state, local) system, Medicaid recipients,
and non-residents

PROGRAM CONTACT

Paul A. Roeger, Division Chief Phone: 410/767-5397


Office of Operations & Eligibility- Fax: 410/333-7290
DHMH E-mail: roeger@dhmh.state.md.us
201 West Preston Street
Baltimore, MD 21201

National Pharmaceutical Council 5-13


Pharmaceutical Benefits 2000

Maryland
Short-Term Prescription Drug Subsidy Plan
Program Type: Direct Assistance
Enacted: 2000
Number of Recipients (FY 00): 1,004

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+* Eligibility Age (Disabled): N/A


Eligible Income Level (Single): N/A Eligible Income Level (Married): N/A
Other Eligibility Notes: *And eligible for Medicare+Choice. Limited to residents of 17
underserved counties

FUNDING AND REIMBURSEMENT

Funding Source: N/A


Budget: N/A
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Enrollment Fee: $460/annually
Deductible Amount: $50
Copayment Amount: $10 for generics, $20 for branded products
Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: N/A
Drugs Covered: N/A
Drug Coverage Restrictions: Maximum benefit of $1,000 per year
Notes:

PROGRAM CONTACT

Secretary of Health and Mental Hygiene


201 West Preston Street
Baltimore, MD 21201

5-14 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Massachusetts
The Pharmacy Program
(formerly Senior Pharmacy Assistance Program)

Program Type: Direct Assistance


Year Operational: 1997
Number of Recipients (FY 99): 24,934

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): $15,708 Eligible Income Level (Married): $21,576
Other Eligibility Notes: Six month Massachusetts residency required; no enrollees receiving
drug coverage from MassHealth or CommonHealth; disabled
participants must work 40 hours per month and meet guidelines for
CommonHealth

FUNDING AND REIMBURSEMENT

Funding Source: Cigarette tax revenues and general revenue fund


Budget: $30 million
Cost per Participant (FY 99): $735
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: WAC+10% or lowest and customary fee
Enrollment Fee: $15.00/annually
Deductible Amount: None
Copayment Amount: $3.00 (generic), $10.00 (brand)
Dispensing Fee: $3.00

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All therapeutic classes except those excluded from MassHealth. Some
prior authorizations are required
Drug Coverage Restrictions: Annual limit of $1,250 per person
Medicaid (MassHealth) recipients are ineligible for the program
Notes:

PROGRAM CONTACT

Sheila Martin Phone: 617/727-7750


Senior Pharmacy Program Fax: 617/727-9368
One Ashburton Place, Room 517
Boston, MA 02108

National Pharmaceutical Council 5-15


Pharmaceutical Benefits 2000

Massachusetts
Pharmacy Program Plus
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 7,170

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $41,220 Eligible Income Level (Married): $55,320
Other Eligibility Notes: Eligibles must have spent at least 10% of gross monthly income on
prescription drugs in 3 of 6 months prior to enrollment and must
project to have drug expenses greater than 5% of gross monthly
income as long as eligible under program.

FUNDING AND REIMBURSEMENT

Funding Source: Cigarette tax revenues and general revenue fund


Budget: N/A
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: WAC+10% or lowest and customary fee
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $3 for generics, $10 for branded products
Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All therapeutic classes except those excluded from MassHealth. Some
prior authorizations are required
Drug Coverage Restrictions: N/A
Notes: Once enrolled in The PHARMACY Program Plus and exhausted all
other prescription benefits, including Medicare HMO or The
PHARMACY Program prescription benefits, enrollees will receive
unlimited prescription coverage to pay for their prescription
medicines.

PROGRAM CONTACT

Sheila Martin Phone: 617/727-7750


Senior Pharmacy Program Fax: 617/727-9368
One Ashburton Place, Room 517
Boston, MA 02108

5-16 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Michigan
Emergency Pharmaceutical Program for Seniors (MEPPS)
Program Type: Direct Assistance
Year Operational: 1990
Number of Recipients (FY 99): 12,968

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $12,360 Eligible Income Level (Married): $16,596
Other Eligibility Notes: Rx drug costs must be 10% (Single)/8% (Married) or more of the
monthly income

FUNDING AND REIMBURSEMENT

Funding Source: Construction tax


Budget: $6 million
Cost per Participant (FY 99): $33.00
# of Rx’s Per Participant (FY 99): 6
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13.5%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Voluntary copay: $0.25/Rx
Dispensing Fee: $3.72

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All prescriptions
Drug Coverage Restrictions: • Coverage limited to 3 months per year
• Generics must be dispensed unless specified by the physician
• No experimental or over-the-counter drugs
Notes: Funding cap on total spending set by legislature. Michigan also has a
tax credit program with a pro rata adjustment to tax credits based
upon funding cap set by legislature. Program will be phased out in
2001 by the new Elder Prescription Insurance Coverage (EPIC)
Program.

PROGRAM CONTACT

Alisa Hamilton Phone: 517/373-7881


Office of Services to the Aging Fax: 517/373-4092
611 West Ottawa, P.O. Box 30676
Lansing, Michigan 48909-8176

National Pharmaceutical Council 5-17


Pharmaceutical Benefits 2000

Michigan
State Medical Plan
Program Type: Tax Credit
Year Operational: 1990
Number of Recipients (FY 00): 20,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): None Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPL
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Construction tax


Budget: N/A
Cost per Participant (FY 99): None
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Enrollment Fee: N/A
Deductible Amount: N/A
Copayment Amount: N/A
Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All prescriptions
Drug Coverage Restrictions:
Notes: Seniors are eligible to a refundable tax up to $600 for prescription
drug expenditures that exceed 5% of income. Program will be phased
out in 2001 by the new Elder Prescription Insurance Coverage (EPIC)
Program.

PROGRAM CONTACT

Alisa Hamilton Phone: 517/373-7881


Office of Services to the Aging Fax: 517/373-4092
611 West Ottawa, P.O. Box 30676
Lansing, Michigan 48909-8176

5-18 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Minnesota
Senior Citizen Drug Program
Program Type: Direct Assistance
Year Operational: 1999
Number of Recipients (00): 5,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $10,260 Eligible Income Level (Married): $13,740
Other Eligibility Notes: Cannot have other prescription drug coverage in past four months or
Medigap. Legislative action will make certain qualifying disabled
persons under the age of 65 eligible for the program starting in 7/1/02

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund plus rebates (subject to budget appropriations)
Budget: $19 million for FY 00 and FY 01
Cost per Participant (FY 99): $725.30 (for the 2,167 elderly recipients in FY 99)
# of Rx’s Per Participant (FY 99): 24.07 (for the 2,167 elderly recipients in FY 99)
Manufacturer Rebate Type: Same as Medicaid minus any CPI add-on
Ingredient Cost Calculation: AWP – 9%
Enrollment Fee: None
Deductible Amount: $35/month
Copayment Amount: None
Dispensing Fee: None

DRUGS COVERAGE

Formulary: Closed Formulary


Drugs Covered: Same drugs as paid under Medicaid if manufacturer signs rebate
agreement with Dept. of Human Services. Covers over-the-counter
drugs for antacid, insulin products, and vitamins
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered
Notes:

PROGRAM CONTACT

Steven Hamilton Phone: 651/296-6627


Department of Human Services Fax: 651/282-6744
444 Lafayette Road E-mail: steven.hamilton@state.mn.us
St. Paul, MN 55155-3853

National Pharmaceutical Council 5-19


Pharmaceutical Benefits 2000

Missouri
State Income Tax Credit for Legend Drugs
Program Type: Tax Credit
Year Operational: 1999
Number of Recipients (FY 00): N/A

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): <$15,000 Eligible Income Level (Married): N/A
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: N/A


Budget: N/A
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: N/A
Notes: Income tax credit for legend drugs. Income up to $15,000 = $200
credit. Credit reduced by $2 for each addition $100 of income.

DRUGS COVERAGE

Formulary: N/A
Drugs Covered: Legend drugs only
Drug Coverage Restrictions: N/A
Notes:

PROGRAM CONTACT

Department of Revenue Phone: 573/751-4081


301 West High Street
Jefferson City, MO 65101

5-20 National Pharmaceutical Council


Pharmaceutical Benefits 2000

New Hampshire
Senior Prescription Drug Discount Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Number of Eligibles: 75,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): None Eligible Income Level (Married): None
Other Eligibility Notes: Must be a New Hampshire resident

FUNDING AND REIMBURSEMENT

Funding Source: Rebates and incentives from pharmaceutical manufacturers


Budget: N/A
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Deductible Amount: None
Copayment Amount: N/A
Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: Most frequently prescribed medication for this population for multiple
health problems
Drug Coverage Restrictions: N/A
Notes: Discounts will vary depending on pharmacy and medication.
Discounts could be up to 40% for generics and up to 15% for branded
products

PROGRAM CONTACT

Health And Human Services Phone: 800/351-1888


Division Of Elderly And Adult
Services
129 Pleasant Street
Concord, NH 03301

National Pharmaceutical Council 5-21


Pharmaceutical Benefits 2000

New Jersey
Pharmaceutical Assistance to the Aged and Disabled (PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Number of Recipients (FY 00): 187,358
(Elderly: 163,958; Disabled: 23,400)

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $18,587 Eligible Income Level (Married): $22,791
Other Eligible Groups: Groups receiving Social Security Disability Benefits are eligible

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund and Casino Revenue Fund


Budget: $273 million
Cost per Participant (FY 99): Elderly: $1,313 (gross), $1,116 (net);
Disabled: $2,654 (gross), $1,974 (net)
# of Rx’s Per Participant (FY 99): 30 Elderly; 43 Disabled
Manufacturer Rebate Type: Medicaid without CPI component
Ingredient Cost Calculation: AWP – 10%, Federal MAC, or Usual & Customary
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00
Dispensing Fee: $3.73 - $4.07

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: All legend drugs, syringes, needles, and diabetic testing materials
Drug Coverage Restrictions: DESI drugs, non-rebatable drugs, and over-the-counter drugs
Prescription Drug Utilization: Branded: $273,946,609 (3,817,842 scripts)
Generic: $37,180,099 (2,455,755 scripts)

PROGRAM CONTACT

Kathleen Mason Phone: 609/588-7032


PAAD Program Fax: 609/588-7037
P.O. Box 715 E-mail: kmason@doh.state.nj.us
Trenton, NJ 08625

5-22 National Pharmaceutical Council


Pharmaceutical Benefits 2000

New York
Elderly Pharmaceutical Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (FY 99): 118,431

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $35,000 Eligible Income Level (Married): $50,000
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund and tobacco tax and settlement funds
Budget: $252.2 million
Cost per Participant (FY 99): $890 (net state cost)
# of Rx’s Per Participant (FY 99): 32
Manufacturer Rebate Type: Same as Medicaid, with modified additional (CPI) rebates
Ingredient Cost Calculation: AWP (less 5% for high volume pharmacies)
Enrollment Fee: Lower income seniors only (<$20,000 if single, <$26,000 if married )
$8-$300 depending on total income and marital status
Deductible Amount: Upper income seniors only (over $20,000 single; over $26,000
married); $530-$1,715 depending on total income and marital status
Copayment Amount: $3 to $20 based on cost of prescription
Dispensing Fee: $2.75 ($3.00 for full-service pharmacies)
Notes: Based on level of income, seniors may enroll in the Fee Plan or the
Deductible Plan.

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: All legend drugs, insulin, and insulin syringes and needles
Drug Coverage Restrictions: DESI drugs and non-participating manufacturers. Viagra limited to six
tables per month
Prescription Drug Utilization: 86% of prescription drug spending on branded; 16% spending on
generic
61% of scripts were branded; 39% of scripts were generic.

PROGRAM CONTACT

Julie A. Naglieri, Acting Director Phone: 518/452-6828


NYS Department of Health, EPIC Program Fax: 518/452-6882
260 Washington Avenue Ext. E-mail: jab15@health.state.ny.us
One Corporate Plaza, Suite 101
Albany, NY 12203

National Pharmaceutical Council 5-23


Pharmaceutical Benefits 2000

North Carolina
Prescription Drug Assistance Plan
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (FY 00): 2,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): 150% FPL Eligible Income Level (Married): 150% FPL
Other Eligibility Notes: Individuals must have cardiovascular disease and/or diabetes

FUNDING AND REIMBURSEMENT

Funding Source: N/A


Budget: $500,000
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: N/A
Copayment Amount: $6.00
Dispensing Fee: N/A

DRUGS COVERAGE

Formulary: N/A
Drugs Covered: Only certain drugs used to treat cardiovascular disease and/or diabetes
Drug Coverage Restrictions: Program will not pay for other drugs
Notes: Prescriptions may be issued for up to a 100-day supply

PROGRAM CONTACT

Charles Reed Phone: 919-715-3338


Department of Health and Human
Services
2001 Mail Service Center
Raleigh, NC 27699

5-24 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Pennsylvania
Pharmaceutical Assistance Contract for the Elderly (PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (FY 00): 208,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $14,000 Eligible Income Level (Married): $17,200
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery


Budget: $290 million (subject to annual legislative appropriations)
Cost per Participant (FY 99): $1,350
# of Rx’s Per Participant (FY 99): 40
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP - 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $6.00
Dispensing Fee: $3.50

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All federal legend drugs and insulin, insulin syringes and needles
manufactured by companies who participate in the PACE rebate
program
Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs,
most off-label uses; mandatory generic substitution for A-rated
products; DESI drugs require documentation of medical necessity.
Prescription Drug Utilization $243,112,901 program spending for brand drugs; 5,498,976 scripts.
$63,066,626 program spending for generic drugs; 3,760,786 scripts.
Notes:

PROGRAM CONTACT

Thomas Snedden Phone: 717/787-7313


PA Department of Aging Fax: 717/772-2730
555 Walnut Street, 5th Floor E-mail: tsnedden@aging.state.pa.us
Harrisburg, PA 17101-1919

National Pharmaceutical Council 5-25


Pharmaceutical Benefits 2000

Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (FY 00): 22,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): $16,000 Eligible Income Level (Married): $19,200
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery


Budget: $290 million (subject to annual legislative appropriations)
Cost per Participant (FY 99): $330
# of Rx’s Per Participant (FY 99): 10
Manufacturer Rebate Type: Mandatory 17% of AMP on all units reimbursed
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: $500 per year
Copayment Amount: $15.00 brand name, $8.00 generic
Dispensing Fee: $3.50

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: All federal legend drugs and insulin, insulin syringes and needles
manufactured by companies who participate in the PACE rebate
program
Drug Coverage Restrictions: No experimental drugs or drugs for baldness and wrinkles, OTCs, most
off-label uses; mandatory generic substitution for A-rated products;
DESI drugs require documentation of medical necessity
Notes:

PROGRAM CONTACT

Thomas Snedden Phone: 717/787-7313


PA Department of Aging Fax: 717/772-2730
555 Walnut Street, 5th Floor E-mail: tsnedden@aging.state.pa.us
Harrisburg, PA 17101-1919

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Pharmaceutical Benefits 2000

Rhode Island
Pharmaceutical Assistance for the Elderly (RIPAE)
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (FY 99): 31,000

ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A
Eligible Income Level (Single): <$35,000 Eligible Income Level (Married): <$40,000
Other Eligible Groups: None
FUNDING AND REIMBURSEMENT
Funding Source: State General Revenue Fund
Budget: $8.5 million for FY 01 (subject to legislature and governor
appropriation yearly)
Cost per Participant (FY 99): $123.99
# of Rx’s Per Participant (FY 99): 19.5
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Copayment amount is based on yearly income:
Single Married Copayment
$15,932 or less $19,916 or less 40%
$15,933 to $20,000 $19,917 to $25,000 70%
$20,001 to $35,000 $25,001 to $40,000 85%

Dispensing Fee: $2.75 per Rx


DRUGS COVERAGE
Formulary: Open Formulary
Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and
chronic respiratory conditions, cancer, circulatory insufficiency,
depression, diabetes (including insulin syringes), heart problems, high
cholesterol, hypertension, Parkinson’s disease, glaucoma, prescription
mineral and vitamin supplements for renal patients, urinary
incontinence.
Drug Coverage Restrictions: Limited by therapeutic class
Notes:
PROGRAM CONTACT
Denis Costa Phone: 401/222-2858 x105
Rhode Island Dept. of Elderly Affairs Fax: 401/222-3389
160 Pine St. E-mail: dennis@dea.state.ri.us
Providence, RI 02903

National Pharmaceutical Council 5-27


Pharmaceutical Benefits 2000

Vermont
VSCRIPT
Program Type: Direct Assistance
Year Operational: 1989
Number of Recipients (FY 00): 2,125

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any age


Eligible Income Level (Single): $18,540 Eligible Income Level (Married): $24,885
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: Cigarette tax revenue and federal funding


Budget: $1.1 million
Cost per Participant (FY 99): $232.00
# of Rx’s Per Participant (FY 99): 4
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $1.00 to $2.00 based on prescription cost
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: Maintenance drugs only.
Drug Coverage Restrictions: No experimental or over-the-counter drugs.
Notes: Health Trust Fund is paid for by an increase in the tobacco tax.
Program only covers maintenance drugs, not acute drugs.

PROGRAM CONTACT

Paul Wallace-Brodeur Phone: 802/241-3985


Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

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Pharmaceutical Benefits 2000

Vermont
Health Access Plan (VHAP)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (FY 00): 7,303

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Any age


Eligible Income Level (Single): $12,360 Eligible Income Level (Married): $16,590
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: Cigarette tax revenue and federal funding


Budget: $9.94 million
Cost per Participant (FY 99): $901.00
# of Rx’s Per Participant (FY 99): 11
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $1.00 to $2.00 based on prescription cost
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: Approved prescription medications
Drug Coverage Restrictions: No experimental or over-the-counter drugs
Notes: None

PROGRAM CONTACT

Paul Wallace-Brodeur Phone: 802/241-3985


Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

National Pharmaceutical Council 5-29


Pharmaceutical Benefits 2000

West Virginia
Senior Prescription Assistance Network II (SPAN II)
Program Type: State-Negotiated Discount
Year Operational: 2000
Number of Recipients (FY 00): 2,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): N/A


Eligible Income Level (Single): <$25,050 Eligible Income Level (Married): <$33,750
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: N/A


Budget: N/A
Cost per Participant (FY 99): N/A
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: N/A
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: N/A
Dispensing Fee: N/A
Notes: Enrollees will receive discounts on prescription drugs

DRUGS COVERAGE

Formulary: No Formulary
Drugs Covered: All FDA approved Federal legend pharmaceuticals
Drug Coverage Restrictions: Cannot be used in conjunction with other discount programs or
prescription drug coverage plans
Notes:

PROGRAM CONTACT

WV Bureau of Senior Services Phone: 877/987-4463


1900 Kanawha Boulevard, East
Holly Grove, Building #10
Charleston, WV 25305-0160

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Pharmaceutical Benefits 2000

Wyoming
Minimum Medical Program
Program Type: Direct Assistance
Year Operational: 1988
Number of Recipients (FY 00): 550

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): Any age Eligibility Age (Disabled): Any age
Eligible Income Level (Single): $8,350 Eligible Income Level (Married): 100% of FPL
Other Eligible Groups: None

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget: Approximately $600,000
Cost per Participant (FY 99): $1,174
# of Rx’s Per Participant (FY 99): N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: AWP – 4%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $25.00/Rx (3 Rx/month cap)
Dispensing Fee: $4.70

DRUGS COVERAGE

Formulary: Open Formulary


Drugs Covered: Approved prescription medications
Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant
products, or fertility promotion agents.
Notes: Health Trust Fund is paid for by an increase in the tobacco tax.
Program only covers maintenance drugs, not acute drugs.

PROGRAM CONTACT

Roxanne Homar, R.Ph. Phone: 307/777-6032


Community and Family Health Fax: 307/777-6964
Division E-mail: rhomar@state.wy.us
Hathaway Bldg, Rm 157
2300 Capitol Ave.
Cheyenne, WY 82002

National Pharmaceutical Council 5-31


Pharmaceutical Benefits 2000

5-32 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Section 6:
State Pharmacy Program
Profiles

National Pharmaceutical Council 6-1


Pharmaceutical Benefits 2000

6-2 National Pharmaceutical Council


Pharmaceutical Benefits 2000

Profiles of State Medicaid Drug Programs


In the following state profiles, we present a general overview of the
characteristics of state programs together with detailed information on the
pharmaceutical benefits provided. Specifically, the following information is
provided for each state:
A. Benefits Provided and Groups Eligible
B. Expenditures for Drugs
C. Administration
D. Provision Relating to Drugs, including:
• Drug Benefit Product Coverage
• Over-the-Counter Product Coverage
• Therapeutic Category Coverage
• Coverage of injectables, vaccines, and unit dosing
• Formulary/Prior Authorization
• Prescribing or Dispensing Limitations
• Drug Utilization Review
• Dispensing Fee
• Ingredient Reimbursement Basis
• Prescription Charge Formula
• Maximum Allowable Cost
• Incentive Fee
• Patient Cost Sharing
• Cognitive Services
E. Use of Managed Care
F. State Contacts

National Pharmaceutical Council 6-3


Pharmaceutical Benefits 2000

ALABAMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD MLIF OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services *
*Dental Services EPSDT - under 21 years old.
1
See Appendix E, page E-29, for a list of acronyms.
B. EXPENDITURES FOR DRUGS
1998* 1999*
Expended Recipients Expended Recipients
TOTAL $236,674,147 395,290

CATEGORICALLY NEEDY RECEIVING


MAINTENANCE ASSISTANCE, TOTAL
Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

CATEGORICALLY NEEDY NOT RECEIVING


MAINTENANCE ASSISTANCE, TOTAL
Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

MEDICALLY NEEDY TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients
Source: HHS State HCFA-2082 Reports.
*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Prescribing or Dispensing Limitations

Alabama Medicaid Agency. Prescription Refill Limit: Maximum of five refills.

D. PROVISIONS RELATING TO DRUGS Drug Utilization Review

Benefit Design PRODUR system implemented in July 1996. State


currently has a DUR Board with a quarterly review.
Drug Benefit Product Coverage: Products covered:
cosmetics; prescribed insulin, disposable needles and Pharmacy Payment and Patient Cost Sharing
syringe combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Dispensing Fee: $5.40.
interdialytic parenteral nutrition. Prior authorization
required for: cosmetics, Retin A, Accutane, Dipyridamole. Ingredient Reimbursement Basis: AWP-10%, WAC +
Products not covered: fertility drugs and experimental 9.2%.
drugs.
Prescription Charge Formula: Medicaid pays for
Over-the-Counter Product Coverage: Products covered if prescribed legend and non-legend drugs authorized under
prescribed by a physician: allergy, asthma and sinus the program based upon and shall not exceed the lowest
products; analgesics; cough and cold preparations; of:
digestive products, topical products; antidiabetic products; 1. The Maximum Allowable Cost (MAC) of the drug
prenatal vitamins; hemorrhoidal products. Products not plus a dispensing fee,
covered: smoking deterrent products and feminine 2. The Estimated Acquisition Cost (EAC) of the drug
products. plus a dispensing fee, or
Therapeutic Category Coverage: Therapeutic categories 3. The provider’s usual and customary charge to the
covered: antibiotics; anticoagulants; anticonvulsants; public for the drug.
antidepressants; antidiabetic agents; antilipemic agents; Maximum Allowable Cost: State imposes Federal Upper
anxiolytics, sedatives, and hypnotics; cardiac drugs; Limits as well as state-specific limits on generic drugs.
chemotherapy agents; contraceptives; estrogens; Override requires “Brand Medically Necessary.”
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); thyroid agents. Prior authorization required Incentive Fee: None.
for: anabolic steroids; analgesics, antipyretics, NSAIDs;
antihistamine drugs; anti-psychotics; ENT anti- Patient Cost Sharing: Variable copayment.
inflammatory agents; growth hormones; nutritional
supplements. Therapeutic categories not covered: Drug Ingredient Cost Copayment
anorectics; prescribed smoking deterrents. $0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
Coverage of Injectables: Injectable medicines $25.01 to $50.00 $2.00
reimbursable through the Prescription Drug Program $50.01 or more $3.00
when used in physician offices, home health care, and Exemptions: No copayment amount is to be collected by
extended care facilities. the pharmacy or paid by the recipient for recipients under
age 18, pregnant or living in nursing facilities.
Vaccines: Vaccines reimbursable as part of the EPSDT
service and the Vaccines for Children Program. Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging reimbursable.
E. USE OF MANAGED CARE
Formulary/Prior Authorization
Does not use MCOs to deliver services to Medicaid
recipients.
Formulary: Open formulary.

Prior Authorization: State currently has a formal prior


authorization procedure. Review by Medicaid’s Assoc.
Medical Director required for appeal of prior
authorization decisions.

National Pharmaceutical Council Alabama-2


Pharmaceutical Benefits 2000

Kelly S. Derbin, M.D.


F. STATE CONTACTS University of South Alabama
Department of Family Practice
State Drug Program Administrator 1504 Springhill Avenue
Louise F. Jones Mobile, AL 36604
Alabama Medicaid Agency 335/434-3489
501 Dexter Avenue
P.O. Box 5624 Keith Fuller, D.O.
Montgomery, AL 36103-5624 2125 Executive Park Drive
T: 334/242-5039 Opelika, AL 36801
F: 334/353-7014 334/741-0075
E-mail: lljones@Medicaid.state.al.us
Agency Internet Address: www.medicaid.state.al.us William P. McCann, M.D.
University of Alabama Birmingham
Prior Authorization Contact School of Medicine
3875 South Cove Drive
Larry Tatum, 334/242-5489 Birmingham, AL 35213
205/934-7047
DUR Contact
Louise Jones, 334/353-7014 John Searcy, M.D.
Alabama Medicaid Agency
Medicaid DUR Board Medical Director
501 Dexter Avenue
Keith Campagna, Pharm.D. Montgomery, AL 36130
Auburn University 334/242-5619
Montgomery Family Medicine Residence Program
4371 Narrow Lane Rd. Suite 100 Sara Redden, R.Ph.
Montgomery, AL 36116 3654 Wiley Road
334/613-3687 Montgomery, AL 36106
334/286-3201
Betty McCamy, R.Ph.
Wal-Mart Pharmacy John E. Brandon, M.D.
102 Lanceleaf Court Intersection Highway 82 and 86
Dothan, AL 36303 P.O. Box 390
334/792-5131 Gordo, AL 35466
205/364-7135
Terry Wingo
Madison Drugs Larry Tatum, R.Ph.
7131 University Drive Alabama Medicaid Agency
Huntsville, AL 35806 Senior Pharmacist
256/837-1747 334/242-5489

Tim Covington, Pharm.D., Chair Mike Mikell, R.Ph.


Samford University Mike’s Pharmacy
2024 Glen Eagle Road P.O. Box 1006
Birmingham, AL 35242 Millbrook, AL 36054
205/870-2988 334/285-5154

Richard L. Bendinger, M.D. Richard Freeman, M.D.


217 Dothan Road 411 B Opelika Road
Abbeville, AL 36310 Auburn, AL 36830
334/585-6421 334/821-4766

3-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2000

Larry A. Tatum, R.Ph., Associate Director


Prescription Price Updating
Pharmaceutical Programs
First DataBank Alabama Medicaid Agency
1111 Bayhill Drive, Suite 350 501 Dexter Avenue; P.O. Box 5624
San Bruno, CA 94066 Montgomery, AL 36103
650/588-5454 334/242-5489

Medicaid Drug Rebate Contacts Title XIX Medical Care Advisory Committee
Technical: Jim Morrison, 334/242-2323 Medical Association of State of Alabama
Policy: Larry Tatum, 334/242-5489 Marsha D. Raulerson, M.D.
Audits: Jim Morrison 334/242-2323 1205 Belleville Avenue
Brewton, AL 36426-1304
Claims Submission Contact 334/867-3609
Ricky Pope
Roy T. Hager, M.D.
Account Manager, EDS
Institute for Total Eye Care
301 Technacenter Dr.
4255 Carmichael Ct. North
Montgomery, AL 36117
Montgomery, AL 36106
334/215-0111
334/277-9111
Medicaid Managed Care Contact Alabama Nursing Home Association
Vicki Huff Frank R. Brown, Jr.
Director, Managed Care P.O. Box 190
Alabama Medicaid Agency Cullman, AL 35056
501 Dexter Avenue 334/784-5573
Montgomery, AL 36103-5624
334/242-5011 Montgomery Area Council on Aging
Rose Posey
Disease Management Program/Initiative Contact 115 East Jefferson Street
Montgomery, AL 36104
Mary G. McIntyre, M.D. 334/263-0532
Associate Medical Director
Alabama Medicaid Agency Alabama State Medical Association
501 Dexter Avenue Jefferson Underwood, III, M.D.
Montgomery, AL 36103-5624 1031 Oak Street
334/242-5574 Montgomery, AL 36108
Physician-Administered Drug Program Contact Recipient Representative
Larry Tatum Charles G. Spradling, Jr.
334/242-5472 P.O. Box 11765
Birmingham, AL 35202
Alabama Medicaid Agency Officials 334/328-3540

W. Dale Walley American Academy of Family Physicians


Acting Commissioner Dr. John E. Brandon
Alabama Medicaid Agency P.O. Box 390
501 Dexter Avenue Gordo, AL 35466
P.O. Box 5624 334/364-7135
Montgomery, AL 36103-5624
334/242-5600 S. T. Christian, Ph.D., Professor
University of Alabama at Birmingham
John Searcy, M.D., Director School of Medicine/Behavioral Neurobiology
Professional Services Birmingham, AL 35294
Alabama Medicaid Agency
501 Dexter Avenue; P.O. Box 5624
Montgomery, AL 36103
334/242-5619

National Pharmaceutical Council Alabama-4


Pharmaceutical Benefits 2000

Alabama Pharmaceutical Association Pharmacy and Therapeutics Committee


Danny Cottrell
A.Z. Holloway, M.D., Chair
1335 McMillen, Box 259
2611 Woodley Park Drive
Brewton, AL 36426
Montgomery, AL 36106
334/867-5454
334/288-0009
Alabama State Nurses Association
Richard L. Bendinger, M.D.
Elizabeth Morris
217 Dothan Road
360 N. Hull Street
Abbeville, AL 36310
Montgomery, AL 36130
334/585-6421
334/262-8321
Richard Freeman, M.D.
Alabama Institute for the Deaf and Blind
411 B Opelika Road
Terry Graham, Ed.D.
Auburn, AL 36830
P. O. Drawer 698
334/821-4766
Talladega, AL 35160
334/761-3274
Michael Hogue, Pharm. D.
800 Lakeshore Drive
Consumer Representative
Birmingham, AL 35229
Ruth Smith
205/726-2669
4001 Meadowood Drive
Birmingham, AL 35242
Jimmy Crane
334/290-5187
413 19th Street West
Ensley, AL 35218
Mike Woodall
205/787-4671
Director, Recreation Department
450 Gilmer
Edward Goldblatt
Tallassee, AL 36078
3517 S. Lake Parkway
334/283-4726
Birmingham, AL 35244
205/802-6650
Dr. A. Z. Holloway
2611 Woodley Park Drive
Phil Jenkins, R.Ph.
Montgomery, AL 36116
12740 Country Lane
334/288-0009
Northport, AL 35476
205/391-3636
Alabama Chap. American Academy of Pediatrics
Dr. John Searcy
Roosevelt McCorvey, M.D.
1105 West Main
3088 Rosa L. Parks Avenue
Dothan, AL 36301
Montgomery, AL 36105
334/262-0259
Medicaid Recipient Representative
Gladys Stautner
Ray Thweatt, M.D.
Rt. 4, Box 315
801 Princeton Avenue, SW
Greenville, AL 36037
Suite 506
334/382-6255
Birmingham, AL 35211
205/783-7060
Sabrina Cooper
218 Lands End Avenue
Selma, AL 36701 Executive Officers of State Medical and
334/874-9001 Pharmaceutical Societies
Medical Association of the State of Alabama (MASA)
West Alabama Health Services, Inc.
Cary Kuhlmann
Sandra Hullett, M.D., MPH
19 S. Jackson Street
Health Services Director
P.O. Box 1900
P.O. Box 711
Montgomery, AL 36102-1900
Eutaw, AL 35462
334/263-6441
334/372-3281

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Pharmaceutical Benefits 2000

Alabama State Medical Association Nursing Home Association


Joel Powell, M.D. Margie Sellers
1408 5th Avenue, SE Executive Director
Suite 1 4156 Carmichael Road
Decatur, AL 35601 Montgomery, AL 36106
205/350-3405 334/271-6214

Alabama Pharmacy Association (APA) Alabama Hospital Association


William s. Eley, II Michael Horsley
1211 Carmichael Way President, CEO
Montgomery, AL 36106 500 North East Blvd.
334/271-4222 Montgomery, AL 36117
334/272-8781
Alabama Optometric Association
Amanda Jones Alabama Pharmacy Coop, Inc. (APCI)
Executive Director Danny Johnson
400 South Union Street, Suite 435 P.O. Box 170747
Montgomery, AL 36104 Birmingham, AL 35217-0747
205/870-3301
State Board of Pharmacy
Charles Thomas Electronic Data Systems (EDS)
1 Perimeter Park South, Suite 425 John Craft
Birmingham, AL 35243 P.O. Box 7600
205/967-0130 Montgomery, AL 36107
334/834-8330
Alabama Independent Drugstore Association (AIDA)
Sharon Taylor Alabama Retail Association
400 Interstate Park Drive Charles McDonald
Suite 401 President
Montgomery, AL 36109 #2 North Jackson
334/213-2432 P.O. Box 1909
Montgomery, AL 36102
Alabama Primary Health Care Association 334/263-5757
Al Fox
6008 East Shirley Lane Suite A Provider Notice Correspondence:
Montgomery, AL 36117 Eckerd Corporation
334/271-7068 813/395-6145
CVS/Revco
Alabama Quality Assurance Foundation (AQAF) 205/424-3421 x447
Dr. James DeLong
Medicaid Pharmacy Admin. Service
1 Perimeter Park South, Suite 300
Birmingham, AL 35243
1-888-Medicaid

Department of Health
Jim McVay, Director
343 Monroe Street
Montgomery, AL 36130-3017
334/206-5226

Alabama State Nursing Association


Ruth Harrell
360 North Hull Street
Montgomery, AL 36104-3658

National Pharmaceutical Council Alabama-6


Pharmaceutical Benefits 2000

ALASKA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care     
Outpatient Hospital Care     
Laboratory & X-ray Service     
Skilled Nursing Home Services     
Physician Services     
Dental Services     
1
See Appendix E, page E-29, for a list of acronyms.

B. DRUG PAYMENTS AND RECIPIENTS


1998* 1999
Expended Recipients Expended Recipients
TOTAL $32,887,828 43,734 $41,149,318 51,631

CATEGORICALLY NEEDY CASH TOTAL $35,948,104 34,829


Aged $5,527,030 3,993
Blind $23,025,340 7,586
Disabled $0 0
Children-Families w/Dep. Children $2,038,831 13,499
Adults-Families w/Dep. Children $5,356,902 9,751
Other Title XIX Recipients $0 0

CATEGORICALLY NEEDY NON-CASH TOTAL $0 0


Aged $0 0
Blind $0 0
Disabled $0 0
Children-Families w/Dep. Children $0 0
Adults-Families w/Dep. Children $0 0
Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $1,431,244 11,128


Aged $6,860 6
Blind $0 0
Disabled $0 0
Children-Families w/Dep. Children $1,152,027 9,076
Adults-Families w/Dep. Children $272,355 2,046
Other Title XIX Recipients $0 0

Source: HHS State HCFA-2082 Reports.


*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Alaska National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure. Request for fair hearing required
Department of Health and Social Services, Division of for appealing coverage of an excluded product and PA
Medical Assistance. decision.

D. PROVISIONS RELATING TO DRUGS Prescribing or Dispensing Limitations

Benefit Design Monthly Quantity Limit: Prescriptions are limited to 30-day


supplies. Dispensing of generic multi-source product is
Drug Benefit Product Coverage: Products covered: required.
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test strips; Drug Utilization Review
urine ketone test strips; total parental nutrition; and
interdialytic parenteral nutrition. Prior authorization PRODUR system implemented in June 1995. State
required for: Clorazil; Lupron Depot; ADC infant vitamins; currently has a DUR Board that meets nine times per year.
some DME; Synagis; Pauretin; and Actig Naltrexone.
Products not covered: cosmetics; fertility drugs; and Pharmacy Payment and Patient Cost Sharing
experimental drugs.
Dispensing Fee: No less than $3.45 and no more than the
Over-the Counter Product Coverage: Products covered: 90th percentile of all dispensing fees determined under the
feminine products (vaginal yeast drugs, miconazole, formula:
ctotrimazole); topical products (bacitracin ointment); and
calcium. Products not covered: allergy, asthma and sinus 1) $23,192 added to the number resulting from
products; analgesics; cough and cold preparations; digestive multiplying total prescriptions filled by that pharmacy
products; and smoking deterrent products. in the previous calendar year by 5.070;
Therapeutic Category Coverage: Categories covered: 2) to 1), add the result of multiplying total Medicaid
anabolic steroids; analgesics, antipyretics, NSAIDs; prescriptions filled in the previous calendar year by
antibiotics; anticoagulants; anticonvulsants; anti- 12.44;
depressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, 3) from 2), subtract the result of multiplying the total floor
and hypnotics; cardiac drugs; chemotherapy agents; space volume of the pharmacy in sq. ft. by 2.103;
contraceptives; ENT anti-inflammatory agents; estrogens;
hypotensive agents; miscellaneous GI drugs; and thyroid 4) divide 3) by total prescriptions filled by that pharmacy
agents. Prior authorization required for: growth hormones.
Categories not covered: anorectics; prescribed cold 5) add $0.73 to 4)
medications; amphetamines (except for narcolepsy and
hyperactivity); prescribed smoking deterrents; Ingredient Reimbursement Basis: EAC = AWP - 5%.
sympathominetics (adrenergic); cough suppressants; DESI
drugs; vitamins (except prenatal); and vitamins with
Maximum Allowable Cost: State imposes Federal Upper
fluoride.
Limits on generic drugs. Override requires “Brand
Medically Necessary” with the reason supplied.
Coverage of Injectables: Injectable medicines reimbursable
through the Prescription Drug Program when used in home
Incentive Fee: None.
health care, extended care facilities and through physician
payment when used in physician offices. No injectable drug
Cognitive Services: Does not pay for cognitive services.
list.
Patient Cost Sharing: $2.00 copayment for branded and
Vaccines: Vaccines reimbursable at cost as part of EPSDT
generic products.
service, Children Health Insurance Program and the
Vaccines for Children Program.
E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging reimbursable when used in
long-term care. Does not use MCOs to deliver services to Medicaid
recipients.
Formulary/Prior Authorization

Formulary: No formulary.

National Pharmaceutical Council Alaska-2


Pharmaceutical Benefits 2000

F. STATE CONTACTS Claims Submission Contact


State Drug Program Administrator Rose-Ellen Hope
Pharmacist
Dave Campana, R.Ph. First Health
Division of Medical Assistance 565 Union St. NE #205
4501 Business Park Blvd., Suite 24 Salem, OR 97301
Anchorage, AK 99503 T: 503/391-0184
T: 907/273-3224 F: 503/391-1979
F: 907/561-1684
E-mail: david_campana@health.state.ak.us
Disease Management Program/Initiative Contact
Health and Social Services Department Officials
Bob Labbe
Karen Perdue Director, Division of Medical Assistance
Department of Health and Social Services P.O. Box 110660
Pouch H-01, Juneau, AK 99811-6040 Juneau, AK 99811-0660
907/465-3030 T: 907/465-3355
F: 907/465-2204
Bob Labbe, Director
Division of Medical Assistance, DHSS Physician-Administered Drug Program Contact
Pouch H-07, Juneau, AK 99811
907/465-3355 Tom Porter, M.D.
907/561-2171
Jack Nielson, Deputy Director
Medical Assistance Alaska Medical Care Advisory Committee
4501 Business Park Blvd., Suite 24
Dr. Patricia Connors Allen
Anchorage, AK 99503
2231 N. Jordan Avenue
907/561-2171
Juneau, AK 99801
Prior Authorization Contact Alaska DUR Committee
Dave Campana 907/273-3224 Dave Campana, R.Ph.
4501 Business Park Blvd., Suite 24
DUR Contact Anchorage, AK 99503
Dave Campana 907/273-3224 Thomas Porter, M.D.
4501 Business Park Blvd., Suite 24
Prescription Price Updating Anchorage, AK 99503
Dave Campana 907/273-3224
Richard Reem, M.D.
Medicaid Drug Rebate Contacts 231 Iditarod
Fairbanks, AK 99701-3639
Technical: Velma Drake, 907/561-2171
Policy: Dave Campana, 907/273-3224 Linda Shull, R.Ph.
Audit: Dave Campana, 907/273-3224 1132 Wolkoff
Kodiak, AK 99615

Arthur Hansen, D.D.S.


1329 McGrath Rd.
Fairbanks, AK 99712

Ted Summers
P.O. Box 3126
Palmer, AK 99645

3-Alaska National Pharmaceutical Council


Pharmaceutical Benefits 2000

Executive Officers of State Medical and


Pharmaceutical Societies
Alaska State Medical Association
Jim Jordan
4107 Laurel Street
Anchorage, AK 99508
T: 907/562-2662
F: 907/561-2063

Alaska Pharmaceutical Association


Erin Carey-Byrne, Executive Secretary
Box 10-1185
Anchorage, AK 99510
907/563-8880

Alaska State Board of Pharmacy


Josephine Dawson
Lic. Examiner
P.O. Box 110806
Juneau, AK 99811-0806
907/465-2589

Alaska State Hospital and Nursing Home Association


Harlan R. Knudson
Pres., CEO
319 Seward Street, Suite 11
Juneau, AK 99801
907/586-1790

Alaska Osteopathic Medical Association


Byron Perkins, D.O.
Secretary/Treasurer
P.O. Box 870470
Wasilla, AK 99687
907/745-0170

National Pharmaceutical Council Alaska-4


Pharmaceutical Benefits 2000

ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
of primary care physicians was established to perform the
AHCCCS FEATURES gatekeeping function for the system. Because the primary
care physicians must approve all care, the primary care
The Arizona Health Care Cost-Containment System network eliminated self-referrals to specialists and
(AHCCCS) is a Title XIX (Medicaid) demonstration diminished excessive use of emergency rooms -- both of
project, jointly funded by the federal government and the which have contributed substantially to high medical
State of Arizona. Begun in October 1982, it serves as a costs.
model for providing medical services to the indigent in a
managed care system rather than through fee-for-service Prepaid Capitated Financing
arrangements. Typically, Medicaid programs have
incorporated the traditional hallmarks of the U.S. health It was the intent of the AHCCCS legislation that health
care system: namely, independent providers and fee-for- plans and their providers offer all covered services to
service reimbursement. In contrast, organized health groups of members within a geographical area for a fixed
plans and capitation mark the AHCCCS model. price, for a definite period. The law allowed for the
In traditional Medicaid programs, the states assume establishment of a statewide bidding process to
responsibility for contracting with individual pharmacies accomplish this. Services are provided on a county-by-
and reimbursing them. In the AHCCCS model however, county basis, by prepaid health plans. Providers may bid
the state contracts instead with pre-paid health plans, on a prepaid capitated basis for covered services to be
HMOs and HMO-like entities. These plans are paid on a provided within a particular county. The law allows for
capitation basis and are responsible for providing all of expansion and contraction of bids to achieve the best
the services covered by the program. Thus, the delivery possible system. In the event there are insufficient bids
of pharmacy services is the responsibility of each prepaid for a given area, the legislation permits capped fee-for-
plan. service arrangements. It is intended, however, that capped
fee-for-service will be authorized as a last resort only.
GENERAL INFORMATION
In essence, AHCCCS prepaid health plans (PHPs), health
The Arizona Health Care Cost Containment System maintenance organizations (HMOs), and other types of
(AHCCCS), developed in Senate Bill 1001, was passed by organized health delivery systems charge a fixed fee per
the Legislature and signed by the Governor in November individual enrolled (i.e., a capitation rate) and assume
1981. It contained six major mechanisms for restraining responsibility for providing a broad array of health care
health care costs at the same time ensuring that services to members.
appropriate levels of quality health care services are
provided to eligible persons in a dignified fashion. The Competitive Bidding Process
goal of these 6 items was to contribute to the
establishment of health care financing that is less The statewide competitive aspect of the bid process for
expensive than conventional fee-for-service systems. The selecting providers and offering prepaid capitated services
six mechanisms were: is the most unique feature of the AHCCCS model. A
competition of this magnitude had never been attempted
• Primary Care Physicians Acting as Gatekeepers in any other state. The AHCCCS administration believes
• Prepaid Capitated Financing competitive bidding for health care service contracts, as
• Competitive Bidding Process opposed to conventional negotiation processes, provides
• Cost Sharing accessible cost-effective delivery of health care without
• Limitations on Freedom-of-Choice sacrificing quality performance.
• Capitation of the State by the Federal
Government The AHCCCS administration issues an invitation to
qualified health plans once every five years. Qualified
Primary Care Physicians as Gatekeepers
health plans may bid to offer the full range of AHCCCS
services in one or more counties.
AHCCCS legislation provided that all members must be
under the care and supervision of a primary care physician
who assumed the role of gatekeeper. A statewide network

1-Arizona National Pharmaceutical Council


Pharmaceutical Benefits 2000

Cost Sharing Provider Participation

The fourth major device for containing costs in the Providers may participate in AHCCCS in 2 different
AHCCCS model is a provision for cost sharing by users. ways. First, they may contract with prepaid capitated plans
A statewide co-payment schedule was developed for this as either full or partial benefit providers.
purpose, and the medically needy participate in
coinsurance cost sharing. It is expected that the The second mode of participation is on a capped fee-for-
imposition of nominal co-payments will ensure optimal service basis. Here, providers agree to accept capped fee
effectiveness in the area of service utilization. The co- payments as payments in full for services provided on a
payment schedule accomplishes three objectives: FFS basis.
curtailment of over-utilization; enhancement of patient
dignity; and service utilization by members for truly Functions of the AHCCCS Administration
needed health care. There is no co-payment for drugs and
medication, prenatal care including all obstetrical visits, The Arizona Health Care Containment System
members in long care facilities and for visits scheduled by Administration (AHCCCSA) contracts with full benefit
the primary care physician or practitioner, and not at the capitated health plans to serve AHCCCS members
request of the member. through a network of providers.

Limitations On Freedom-of-Choice Contracting Health Plans

The fifth major item for containing costs is a restriction on Under the Contracting Health Plan arrangement, plans are
provider/physician selection by AHCCCS members. defined in terms of explicit groups of providers organized
Unlike conventional delivery models, Arizona does not as entities that are more formal. These consortia, or
rely on fee-for-service arrangements. The goal is to have formal entities, are capable of providing the full range of
the state completely blanketed with prepaid capitated AHCCCS benefits within a defined service area for all
arrangements. Members are linked to selected or assigned AHCCCS members who elect to join the plans, up to a
plans for definite durations of time. Freedom-of-choice is predetermined capacity. This is the dominant mode of
permitted to the extent practicable for members to select operation within AHCCCS -- with two or more competing
the particular group with which to enroll, as well as the plans wherever possible.
primary care physician within the selected group. Capped
fee-for-service health service arrangements are used as a The Contracting Health Plans are delivery systems, not
last resort, and only in areas not covered by prepaid simply insurance plans, but they need not be Health
capitated plans. Maintenance Organizations by any legal or conventional
definition of the term. The AHCCCS legislation provides
CAPITATION BY THE FEDERAL for the creation of provider consortia for the purpose of
GOVERNMENT participation in the program. The Contracting Health Plan
may be a loosely organized system, but it must be capable
The State of Arizona will itself be capitated by the Federal of providing the full range of AHCCCS benefits to a
Government and therefore will be at financial risk for defined population at a capitation rate.
containing health care costs. Capitation rates will be
established according to sound actuarial principles, and The Organizational Role of AHCCCS
will represent no more than 95 percent of the estimated Administration
cost of services delivered in Arizona under conventional
fee-for-service arrangements. Capitation provides a key The AHCCCS Administration has been charged with the
incentive for the state to monitor health care costs on a general implementation and monitoring of the AHCCCS
careful and continuous basis. program.

The AHCCCS Administration develops the Rules and


IMPLEMENTATION OF AHCCCS
Regulations; manages the health plan bidding processes;
awards the contracts; provides technical assistance to
AHCCCS is based on plans that have been tested, in part,
providers for the purpose of forming consortia to contract
on smaller scales in different areas of the country. By
with AHCCCS; and monitors the overall operation of the
combining a number of key mechanisms on a statewide
program.
basis, AHCCCS represents a novel health care model.
The purpose of this section is to present a discussion of
how the key concepts embodied in the AHCCCS
legislation will be implemented and rendered operational.

National Pharmaceutical Council Arizona-2


Pharmaceutical Benefits 2000

The Operational Role of the AHCCCS Doctor’s Health Plan, P.C. 520/428-7801
Administration 517 Main Street
Stafford, AZ 85546
Organizationally, the AHCCCS Administration assumes
responsibility for the oversight of every day operations. Family Health Plan of NE Arizona 520/921-8944
P.O. Box 2069
The AHCCCS Administration has overall responsibility Cottonwood, AZ 86326
for the following activity areas:
Health Choice Arizona 602/968-6866
• Promotion of AHCCCS Suite 260
• Procurement of Health Plans 1600 West Broadway
• Quality Management Tempe, AZ 85282-1136
• Provider Management
• Provider, Member, and Public Relations Maricopa Managed Care Systems 602/681-8700
• Program Operations 2516 East University Drive
AHCCCS became effective December 1, 1981, and Phoenix, AZ 85034
services commenced October 1, 1982. Services include:
inpatient, outpatient, laboratory, x-ray, prescription drugs, Mercy Care Plan 602/230-9921
medical supplies, prosthetic devices, emergency dental 2800 North Central, Suite 400
care including extractions and dentures, treatment of eye Phoenix, AZ 85004
conditions and EPSDT.
Phoenix Health Plan 602/824-3700
Though AHCCCS was a three-year experiment that was to 2700 North 3rd Street
end in October 1985, the federal government continues to Phoenix, AZ 85004
extend funding for the program. In 1988, AHCCCS
received a five-year extension from the federal Pima Health System 602/512-5500
government and in 1993, it received an additional one- Suite A-200
year extension. In 1994, AHCCCS received a three-year 5055 East Broadway
extension and in 1998, it is expected to receive a one-year Tucson, AZ 85711
extension.
Regional AHCCCS Health Plan 520/426-6648
1955 North Casa Grande Avenue, #116
MEDICAL PLANS AND ADMINISTRATORS Casa Grande, AZ 85222
Contract terminated, effective 5/1/97
AHCCCS Contracted Health Plans
Access Blue Connection 602/864-4445 University Family Care 520/321-7248
2444 W. Las Palmaritas Drive 575 East River Road
Phoenix, AZ 85021 Tucson, AZ 85704
Contract terminated, effective 10/1/97
Phoenix Arizona Indian Health Services (IHS)
Arizona Health Concepts 602/331-5100 Two Renaissance Square 602/640-2120
7600 N. 16th Street, Suite 150 40 N. Central Avenue
Phoenix, AZ 85020 Phoenix, AZ 85004-5036

Arizona Physicians IPA, Inc. 602/274-6102 Phoenix Indian Medical Center 602/263-1200
3141 North 3rd Avenue 4212 North 16th Street
Phoenix, AZ 85013 Phoenix, AZ 85016

CIGNA Community Choice 602/942-4462 Indian Health Services (IHS) 520/295-2550


11001 North Black Canyon Highway Southern Region
Phoenix, AZ 85029 7900 J.J. Stock Road
Tucson, AZ 85746
DES/CMDP 602/351-2245
CMDP-942-C Navajo Area Indian Health Services (IHS)
Century Plaza Building, 10th Floor P.O. Box 9020 520/871-5880
3225 North Central Avenue Window Rock, AZ 86515-9020
Phoenix, AZ 85012

3-Arizona National Pharmaceutical Council


Pharmaceutical Benefits 2000

ALTCS Contractor List STATE CONTACTS


Arizona Physicians IPA (ALTCS)
242 West 28th Street, Suite A AHCCCS Officials
Yuma, AZ 85364 John H. Kelly, Acting Director
520/783-5691 AHCCCS
801 E. Jefferson
Cochise Health Systems Phoenix, AZ 85034
Cochise County Health & Social Services 602/417-4680
Cochise Health Systems
1415 West Melody Lane, Building A Leonard Jasinski, M.D.
Bisbee, AZ 85603 Medical Director
520/432-9481

DES/DDD Executive Officers of State Medical and


1789 West Jefferson, 4th Floor Pharmaceutical Societies
Phoenix, AZ 85034 Arizona Medical Association, Inc.
602/542-6866 Chic Older
Executive Vice President
Maricopa Managed Care Systems 810 West Bethany Home Road
2516 East University Drive Phoenix, AZ 85013
Phoenix, AZ 85034 602/246-8901
602/681-8700
Arizona Pharmacy Association
Pima County LTC Kathy Boyle
Pima Health System Executive Director
Suite A-200, 5055 East Broadway 1845 E. Southern Ave.
Tucson, AZ 85711 Tempe, AZ 852-82-5831
520/512-5500 602/838-3385

Pinal County Health Plan - LTC Arizona Osteopathic Medical Association


P.O. Box 2140 Amanda Weaver
574 South Central Avenue Executive Director
Florence, AZ 85232-2140 5150 N. 16th St., #A122
520/868-6775 Phoenix, AZ 85016
602/266-6699
Ventana Health Systems
Apache, Gila, Graham, Greenlee, Mohave, Arizona Board of Pharmacy
Navajo, LaPaz & Santa Cruz Counties L. A. Lloyd
7600 N. 16th St., Ste. 150 Executive Director
Phoenix, AZ 85020 5060 North 19th Avenue, Ste. 101
602/331-5100 Phoenix, AZ 85015
602/255-5125
Yavapai County LTC
Yavapai County Department of Medical Assistance Arizona Hospital and Healthcare Association
255 East Gurley Street, First Floor John R. Rivers
Prescott, AZ 86301 Pres., CEO
520/771-3560 1501 West Fountainhead Parkway
Suite 650
AHCCCS FFS (ALTCS) Tempe, AZ 85282
Ventilator Dependent 602/968-1083
Central Office (Office of the Medical Director)
602/417-4283

National Pharmaceutical Council Arizona-4


Pharmaceutical Benefits 2000

ARKANSAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs         

Inpatient Hospital Care         

Outpatient Hospital Care         

Laboratory & X-ray Service         

Skilled Nursing Home Services         

Physician Services         

Dental Services         
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999
Expended Recipients Expended Recipients
TOTAL $150,891,615 262,907 $174,122,352 272,863

RECEIVING CASH ASSISTANCE, TOTAL $21,923,101 43,898


Aged $15,746,553 15,658
Blind/Disabled $979,341 919
Child $3,073,535 20,352
Adult $2,123,161 6,967
Unemployed Parent-Child $64 1
Unemployed Parent-Adult $445 1

MEDICALLY NEEDY, TOTAL $90,570,658 20,598


Aged $82,938 4
Blind/Disabled $86,427,655 12,882
Child $1,886,271 7,512
Adult $2,173,792 200

POVERTY RELATED, TOTAL $15,416,172 63,625


Aged $124,995 4
Blind/Disabled $890,988 4
Child $13,586,659 63,573
Adult $813,529 44

OTHER, TOTAL $59,618,981 42,100 $46,212,420 9,548

Source: HHS Report HCFA-2082, Sections A-4 and B-4.


*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.
C. ADMINISTRATION

Department of Human Services, Division of Medical


Services, Pharmacy.

1-Arkansas National Pharmaceutical Council


Pharmaceutical Benefits 2000

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization


Benefit Design Formulary: Closed formulary. General exclusions
include:
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe 1. Agents used for hair growth.
combinations used for insulin. Products not covered: 2. Vitamin products except prescription prenatal
blood glucose test strips; urine ketone test strips; total vitamins.
parenteral nutrition, interdialytic parenteral nutrition; 3. Drugs determined by the FDA to be ineffective
cosmetics; fertility drugs; and experimental drugs. Prior (DESI drugs).
authorization required for: nitroglycerin patches; agents 4. Sedatives and hypnotics in the benzodiazepine
for impotence; Synagis; and Respigam. category (partial coverage).
5. Compounded prescriptions (mixtures of two or more
Over-the-Counter Product Coverage: Products covered: ingredients). States are not allowed to have state
digestive products (H2 antagonist). Limited coverage for: codes such as 99999-9999-99. All drugs reimbursed
allergy, asthma and sinus products; analgesics; cough and by the State must be traced by NDC code and appear
cold preparations; digestive products (non-H2 antagonist ) on the utilization report.
(under 21 years and long-term care limited needs);
feminine products; and topical products. Product not Prior Authorization: State currently has a prior
covered: smoking deterrent products. authorization procedure.

Therapeutic Category Coverage: Therapeutic categories Prescribing or Dispensing Limitations


covered: anabolic steroids; antibiotics; anticoagulants; Prescription Refill Limit: 5 refills within 6 months are
anticonvulsants; anti-depressants; antidiabetic agents; allowed. New Rx required every 6 months.
antilipemic agents; anti-psychotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Monthly Quantity Limit: 30-day supply.
inflammatory agents; estrogens; growth hormones;
hypotensive agents; sympathominetics (adrenergic); and Monthly Prescription Limit: Three prescriptions per
thyroid agents. Prior authorization required for: month per recipient, except unlimited in certified LTC
analgesics, antipyretics, NSAIDs; antihistamine drugs; recipients and recipients under 21 years old. Others can
misc. GI drugs; prescribed smoking deterrents. receive extension of three more per month.
Therapeutic categories not covered: anorectics.
Drug Utilization Review
Coverage of Injectables: Injectable medicines are
reimbursable through the Prescription Drug Program PRODUR system implemented in March 1997. State
when used in home health care, extended care facilities currently has a DUR Board with a quarterly review.
and through physician payment when used in physicians
offices. No injectable drug list. Pharmacy Payment and Patient Cost Sharing

Vaccines: Vaccines reimbursable as part of the Vaccines Dispensing Fee: $5.51 effective 7/1/99.
for Children Program.
Ingredient Reimbursement Basis: EAC = AWP – 10.5%.
Unit Dose: Unit dose packaging reimbursable.
Prescription Charge Formula: Legend drugs: lower of the
EAC plus a dispensing fee or CFA/state upper limit plus a
dispensing fee. Total charge may not exceed provider’s
charge to the self-paying public.

Maximum Allowable Costs: State imposes Federal Upper


Limits as well as state-specific limits on generic drugs.
State-specific MAC list contains 200 drugs. Override
requires “Brand Medically Necessary.” PA must be
obtained once the pharmacy obtains the BNM Rx.

Incentive Fee: None.

National Pharmaceutical Council Arkansas-2


Pharmaceutical Benefits 2000

Patient Cost Sharing: Effective 9/1/92, for each Scott Harris, P.D.
prescription reimbursed, the Medicaid recipient is 9601 I-630, Ext. 7
responsible for paying a copayment based on the Little Rock, AR 72205-1749
following: 501/202-1749
State Payment Copay
Benji Post, P.D.
$10.00 or less $0.50
$10.01 to $25.00 $1.00
Physicians
$25.01 to $50.00 $2.00
Thomas Lewellen, D.O.
$50.01 or more $3.00
105 West Waterman
ArKids $5.00
Dumas, AR 71639
870/382-1188
Services to individuals under 18, pregnant women,
nursing home residents, emergency services, family Michael N. Moody, M.D.
planning services, and services provided by an HMO to its P.O. Box 829
enrollees are excluded from the Medicaid copay policy. Salem, AR 72576
501/895-2541
Cognitive Services: Does not pay for cognitive services.
Charles Rodgers, M.D.
4202 South University
E. USE OF MANAGED CARE
Little Rock, AR 72204
501/562-4838
An estimated 230,000 Medicaid recipients were enrolled
with managed care organizations PCP and ArKids.
Medicaid Pharmacist
Pharmaceutical benefits are provided through the state.
Suzette Bridges
F. STATE CONTACTS Prescription Price Updating
Medicaid Drug Program Administrator First DataBank
1111 Bay Hill Drive
Suzette Bridges, P.D. San Bruno, CA 74066
Division of Medical Services 415/588-5454
Dept. of Human Services
P.O. Box 1437, Slot 4105
Medicaid Drug Rebate Contacts
Little Rock, AR 72203
T: 501/324-9141 Audits: Suzette Bridges, P.D., 501/324-9141
F: 501/324-9140 PA: Mary Alice Easterling, EDS, 501/374-6608
E-mail: suzette.bridges@medicaid.state.ar.us
Claims Submission Contact
Prior Authorization Contact John Herzog
EDS Federal Corp.
Suzette Bridges
500 East Markham, Ste 400
501/324-9141
Little Rock, AR 72201
501/374-6608
Dr. Judith McGhee
501/682-6442DUR Contact
Medicaid Managed Care Contact
Suzette Bridges
Bob Paladino
501/324-9141
P.O. Box 1437, Slot 1102
Little Rock, AR 772203
DUR Board
Pharmacists:
Steve Bryant, P.D.
Bryant’s Pharmacy
2000 Harrison Street
Batesville, AR 72501
501/793-3999

3-Arkansas National Pharmaceutical Council


Pharmaceutical Benefits 2000

CALIFORNIA

A. BENEFITS PROVIDED AND GOUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN)
>21 Children <21
Prescribed Drugs   
Inpatient Hospital Care   
Outpatient Hospital Care   
Laboratory & X-ray Service   
Skilled Nursing Home Services    
Physician Services   
Dental Services   
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related
benefits.
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998 1999*
Expended Recipients Expended Recipients
TOTAL $1,553,598,462 2,644,430

CATEGORICALLY NEEDY, RECEIVING


ASSISTANCE, TOTAL $1,181,162,264 1,564,857
Aged $254,611,395 248,440
Blind/Disabled $812,296,210 536,457
AFDC-Children $35,413,433 383,891
AFDC-Adult $47,289,063 188,195
AFDC-Unemployed-Children $10,991,408 120,991
AFDC-Unemployed-Adults $20,560,755 75,883

MEDICALLY NEEDY, TOTAL $281,093,222 566,080


Aged $105,624,178 111,101
Blind/Disabled $125,615,464 60,154
AFDC-Children $23,988,641 283,220
AFDC-Adult $24,884,939 111,605

POVERTY RELATED, TOTAL $14,965,593 163,798


Aged $732,955 659
Blind/Disabled $578,605 1,319
AFDC-Children $12,486,033 139,977
AFDC-Adult $1,168,000 21,843

OTHER, TOTAL $1,695,126 301,095

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1999 total and expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council California-1


Pharmaceutical Benefits 2000

C. ADMINISTRATION Unit Dose: Reimbursable at buck prices.

Under the Health and Human Services Agency with direct Formulary/Prior Authorization
administration by the Department of Health Services.
Formulary: Closed formulary. Medi-Cal List of Contract
The Department of Health Services Pharmaceutical Unit Drugs: Over 600 drugs in differing strengths and dosage
of the Medi-Cal Policy Division monitors the full scope forms listed generically. A drug may be added to the list
and quality of pharmaceutical benefits covered under the on contractual agreement by the manufacturer to provide
provisions of the California Medical Assistance Program. the state a rebate based on the quantity reimbursed to
pharmacies for Medi-Cal recipients. The patient’s
D. PROVISIONS RELATING TO DRUGS physician or pharmacist may request prior authorization
from the field office Medi-Cal consultant for approval of
Benefit Design unlisted drugs or for listed drugs that are restricted to
specific use(s).
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Examples of general limitations and exclusions (other
combinations used for insulin; blood glucose test strips; uses require prior authorization):
and urine ketone test strips. Products covered with prior
1. CNS stimulants, i.e., amphetamines and
authorization: total parenteral nutrition and interdialytic
methylphenidate, are restricted to attention deficit
parenteral nutrition. Products not covered: cosmetics;
disorder in individuals between 4 and 16 years of age.
fertility drugs; and experimental drugs.
2. Diazepam is restricted to use in cerebral palsy,
Over-the-Counter Product Coverage: Products covered athetoid states, and spinal cord degeneration.
with prior authorization: allergy, asthma and sinus
3. Cimetidine, Famotidine are restricted to therapy
products; analgesics; cough and cold preparations; non-
lasting up to 90 days from the dispensing date of the
H2 antagonist digestive products; digestive products, H2
first prescription.
antagonists; feminine products; topical products; and
smoking deterrent products. 4. Most non-steroidal anti-inflammatory agents are
restricted to use for arthritis.
Therapeutic Category Coverage: Therapeutic categories
5. Many antibiotics have diagnostic and/or age
covered: chemotherapy agents and contraceptives. Prior
restrictions.
authorization required for: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants; 6. Acyclovir capsules are restricted to herpes genitalis,
anticonvulsants; antidepressants; antidiabetic agents; immunocompromised patients and herpes zoster
antihistamine drugs; antilipemic agents; anti-psychotics; (shingles).
anxiolytics, sedatives, and hypnotics; cardiac drugs;
7. Codeine Combinations: payment to a pharmacy for
prescribed cold medications; ENT anti-inflammatory
ASA or APAP with codeine 30 mg is limited to a
agents; estrogens; growth hormones; hypotensive agents;
maximum dispensing quantity of 45 tablets or
misc. GI drugs; prescribed smoking deterrents;
capsules and a maximum of 3 claims for the same
sympathominetics (adrenergic); and thyroid agents. Medi-
beneficiary in any 75-day period.
Cal fee-for-service does not blanket exclude drug classes.
Drugs for the treatment of cancer or AIDS are exempt 8. Excluded from coverage: multivitamins for persons
from prior authorization. over five years of age (except pre-natal vitamin-
mineral products for pregnant women); cosmetic
Coverage of Injectables: Injectable medicines drugs and fertility drugs; and most OTC household
reimbursable through the Prescription Drug Program remedies.
when used in home health care, extended care facilities
9. Enteral nutritional supplements or replacements are
and through physician payment when used in physician
covered, subject to prior authorization, if used as a
offices.
therapeutic regimen to prevent serious disability or
death in patients with medically diagnosed conditions
Vaccines: Vaccines reimbursable by schedule as part of
that preclude the full use of regular foodstuffs.
the Vaccines for Children Program. Vaccines for adults
covered through the prescription drug program. 10. Cancer, AIDS, and DESI Drugs: Any antineoplastic
drug approved by FDA for the treatment of cancer
and any drug approved by FDA for the treatment of
AIDS or AIDS-related condition is covered through
the Medi-Cal List of Contract Drugs; most DESI

2-California National Pharmaceutical Council


Pharmaceutical Benefits 2000

drugs rated less-than-effective by FDA are not Hospital Discharge Medications: Quantities furnished as
covered. discharge medications are limited to no more than a 10-
day supply. Charges are incorporated in the hospital’s
Prior Authorization: State currently has a formal prior
claims for inpatient services.
authorization procedure. Medi-Cal frequently petitions to
add drugs to the list of contract drugs. Denials of these Drug Utilization Review
petitions can be appealed to the director of the
Department of Health and Human Services by the PRODUR system implemented in August 1995. State
petitioner within 30 days after notice of the denial. currently has a DUR Board with a quarterly review.
Providers may appeal prior authorization decisions within
60 days of notification to the local field office and then to Pharmacy Payment and Patient Cost Sharing
field services headquarters if necessary. Beneficiaries also
have the ability to request a hearing to review the denial Dispensing Fee: $4.05, effective 8/85.
and must do so within 90 days of notification.
Ingredient Reimbursement Basis: EAC = AWP-5%, or
Approval may be obtained from a Medi-Cal consultant direct price for 11 specified manufacturers.
for: covered items or services not included on the Medi-
Cal List of Contract Drugs (including special Prescription Charge Formula: Reimbursement is based
circumstance override of multiple source drug price on the lowest of:
ceilings or minimum quantity/ frequency of billing
limitations); and for patients exceeding the 6 Rx per For Legend Drugs:
month limit. Statewide mail and fax requests are accepted 1. Estimated Acquisition Cost (EAC) + dispensing fee,
in the Stockton and Los Angeles Medi-Cal Field Offices. less $0.25.
Requests must include adequate information and 2. Federal Upper Limit (FUL) + dispensing fee, less
justification. Authorization may only be given for the $0.25.
lowest cost item or service that meets the patient’s 3. State Maximum Allowable Ingredient Cost (MAIC) +
medical needs. dispensing fee, less $0.25.
4. Pharmacy’s usual price to general public, less $0.25.
Beneficiary or Prescriber Prior Authorization: On a case
by case basis, the Dept. of Health Services restricts,
through the requirements of prior authorization, the For Over-the-Counter Drugs:
availability of designated prescription drugs to certain 1. Estimated acquisition cost (EAC) x 1.5, less $0.50.
beneficiaries or prescribers found by the Department to 2. Federal Upper Limit (FUL) x 1.5, less $0.50.
abuse those benefits. 3. State Maximum Allowable Ingredient Cost
(MAIC) x 1.5, less $0.50.
Prescribing or Dispensing Limitations 4. Pharmacy’s usual price to the general public, less
$0.50.
Prescription Refill Limit: A prescription refill can be
dispensed as authorized by prescriber. Exception is (Reimbursement is reduced by $0.25 per claim line as of
allowed for refill of a reasonable quantity when prescriber January 1, 2000.
is unavailable (pursuant to California law). Fee is pro-
rated so that total fee (for partial quantity and balance of Maximum Allowable Cost: State MACs are established
the prescription after prescriber is contacted) does not for 51 multi-source items. Override requires “Medically
exceed fee for same prescription when refilled as routine Necessary” or unavailability of drug products at or below
service. MAC. List is periodically revised and price limits
changed to reflect current market conditions.
Monthly Quantity Limit: This is flexible, but should be
consistent with the medical needs of the patient. Limited Incentive Fee: None.
to 100 tabs on some drugs, 100 days’ supply on others.
Many maintenance drugs are subject to minimum quantity Patient Cost Sharing: Copayment: $1.00 (optional).
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month Cognitive Services: Does not pay for cognitive services,
without prior authorization. The limit does not apply to but this is under consideration.
family planning drugs, patients in nursing facilities or to
AIDS or cancer drugs.

National Pharmaceutical Council California-3


Pharmaceutical Benefits 2000

Orange County Organized Health System


E. USE OF MANAGED CARE CalOptima
1120 West La Veta Ave, 5th Floor
Approximately 2,500,000 total unduplicated number of Orange, CA 92668
Medicaid recipients were enrolled in MCOs in FY 1999.
Recipients receive pharmaceutical benefits through the Santa Cruz County -Monterey
state and managed care plans. Managed Care Commission
Kaiser Foundation Santa Cruz County Health Options
Health Plan, Inc. 375 Encinal Street, Suite A
Northern California Region Santa Cruz, CA 95060
1800 Harrison Street, 9th Floor
P.O. Box 12916 Sutter Senior Care
Oakland, CA 94612-2998 1234 U Street
Sacramento, CA 95816
Omni Health Care
2450 Ventura Oaks, Suite 300 Altamed Health Services Corp.
Sacramento, CA 95833-3292 500 Citadel Drive, Suite 490
Los Angeles, CA 90040
Denticare
125 Technology Street CompCare Health Plan, Inc.
Irvine, CA 92618 3200 Fourth Ave, Suite 200
San Diego, CA 92103
Universal Care
1600 E. Signal Hill Street Blue Cross of California
Signal Hill, CA 90806-3682 5151-A Camino Ruiz
Camarillo, CA 93012
County of Contra Costa
Contra Costa Health Plan Kern Health Systems
595 Center Avenue, Suite 100 Kern Family Health care
Martinez, CA 94553 1600 Norris Road
Bakersfield, CA 93308
Western Health Advantage
1331 Garden Highway Suite 100 LA Care Health Plan
Sacramento, CA 95833-9754 3530 Wilshire Boulevard, Suite 704
Los Angeles, CA 90100
CaliforniaCare Health Plans
2000 Corporate Center Dr., Bldg. 7 Inland Empire Health Plan
Newbury Park, CA 91320 303 E. Vanderbilt Way, Suite 400
San Bernardino, CA 92408
Placer County Managed Care Network
11730 Enterprise Drive San Francisco Health Authority
Auburn, CA 95603 San Francisco Health Plan
568 Howard Street, Fifth Floor
Sonoma County Medi-Cal San Francisco, CA 94105
Managed care Network
1221 Farmers Lane, Suite 200 Health Plan of San Joaquin
Santa Rosa, CA 95404-1705 1550 W. Fremont Street
Stockton, CA 95203-2643
Watts Health Foundation, Inc.
United Health Plan Omni Healthcare Inc.
3405 West Imperial Highway, Suite 600 2450 Venture Oaks, Suite 300
Inglewood, CA 90303 Sacramento, CA 95833

Maxicare
1149 South Broadway, Suite 819
Los Angeles, CA 90015

4-California National Pharmaceutical Council


Pharmaceutical Benefits 2000

UCSD Healthcare Center for Elders Independence


200 West Arbor Dr. 1955 San Pablo Ave
San Diego, CA 92103 Oakland, CA 94612

Delta Dental Plan of CA HealthReach Family Care Center


7687 Folsom Blvd 7237 Lennane Drive, Suite 200
Sacramento, CA 95826 Sacramento, CA 95834

Western Dental Srvs., Inc. #424 AIDS Healthcare Foundation


300 Plaza Alicante, Ste. 810 6255 W. Sunset Blvd., 16th Floor
Garden Grove, CA 92640 Los Angeles, CA 90028-8073
Health Net
3400 Data Drive, 1st Fl. W Cohan Medical Corp
Rancho Cordova, CA 95670 Tower Health Services
200 Oceangate, Sixth Pl.
Molina Medical Centers Long Beach, CA 90802
One Golden Shore Drive
Long Beach, CA 90802 Alameda Alliance for Health
1850 Fairway Drive
Orange County Organized Health System San Leandro, CA 94557
CalOptima
1120 West la Veta Ave., 5th Floor San Francisco City & County Public Health
Orange, CA 92668 Family Mosaic Project
1309 Evans Avenue
San Mateo Health Commission San Francisco, CA 94124
Health Plan of San Mateo
1500 Fashion Island Blvd., Suite 300 Scan Health Plan
San Mateo, CA 94404 Senior Care
Action Network
Santa Barbara County Special Healthcare Authority 3780 Kilroy Airport Way, Suite 600
Santa Barbara Health Initiative Long Beach, CA 90806-2460
110 Castilian Dr.
Goleta, CA 93117-3028 Santa Clara Family Health Plan
4050 Moopark Avenue
Solano County Medical Care Commission San Jose, CA 95117
Solano Partnership Health Plan
421 Executive Court North, Suite A Access Dental Plan, Inc.
Suisun City, CA 94585 555 University Ave, Suite 182
Sacramento, CA 95825
Solano-Napa County
Commission on Medical Care
Partnership HealthPlan of California F. STATE CONTACTS
421 Executive Court North, Suite A
Suisun City, CA 94585 State Drug Program Administrator
J. Kevin Gorospe, Pharm.D.
Santa Cruz-Monterey Chief, Pharmaceutical Unit
Managed Medical Care Commission Medi-Cal Policy Division
Central Coast Alliance for Health 714 P Street, Room 1540
375 Encinal Street, Suite A Sacramento, CA 95814
Santa Cruz, CA 95060 T: 916/657-4213
F: 916/654-0513
OnLok Senior Health Services E-mail: kgorospe@dhs.ca.gov
1441 Powell Street Agency Internet Address: http://www.dhs.ca.gov
San Francisco, CA 94133-3879

National Pharmaceutical Council California-5


Pharmaceutical Benefits 2000

Prior Authorization Contact Medicaid Drug Rebate Contacts


DUR: Vic Walker, R.Ph., B.C.P.P. 916/657-0785
J. Kevin Gorospe, 916/657-4213
PA: J. Kevin Gorospe, Pharm.D., 916/657-4213
DUR Contact
Claims Submission Contact
Vic Walker, R.Ph. B.C.P.P
Dennis Dworman
Sr. Pharmaceutical Consultant
Executive Program Director
Medi-Cal Policy Division
EDS-Medi-Cal
714 P Street, Room 1540
Electronic Data Systems
Sacramento, CA 95814
3215 Prospect Park Drive
T: 916/654-0785
Rancho Cordova, CA 95670
F: 916/654-0513
916/636-1000
E-mail: vwalker@dhs.ca.gov
Medicaid Managed Care Contact
Medi-Cal Drug Utilization Review Board (DUR
Board)
Susanne Hughes
Timothy E. Albertson, M.D., Ph.D. Acting Division Chief
University of California-Davis Medi-Cal Managed Care Division
Pulmonary/Critical Care Medicine 714 P Street, Room 650
4301 X Street, Professional Bldg., Room 2120 Sacramento, CA 95814
Sacramento, CA 95817 T: 916/654-8076
F: 916/657-2069
Robert J. Matutat, Pharm.D. E-mail: shughes2@dhs.ca.gov
First Databank
Attn: inpatient Pharmacy Disease Management Program/Initiative Contact
1425 S. Main
J. Kevin Gorospe, 916/657-4213
Walnut Creek, CA 94596
Physician-Administered Drug Program Contact
Janeen G. McBride, R.Ph.
Rx America Fulton Lipscomb, M.D.
1500 South Anaheim Blvd. 916/657-1460
Anaheim, CA 92815-0017
Health and Welfare Agency Officials
Gary M. McCart, Pharm.D.
Grantland Johnson
University of California, San Francisco
Secretary
400 Parnassus Ave., Box 312
California Health and Human Services Agency
San Francisco, CA 94143
1600 9th Street, Suite 460
Sacramento, CA 95814
Anoush Miridjanian, M.D.
Southern California Permanente Medical Group
Diana Bonta, R.N., Director
Department of Internal Medicine
Department of Health Services
4647 Zion Ave.
714 P Street, P. O. Box 942732
San Diego, CA 92120
Sacramento, CA 95814
Stephen M. Stahl, M.D., Ph.D.
Gail L. Margolis, Acting Deputy Director
Clinical Neuroscience Research Center
Medical Care Services
8899 University Center Lane, Ste. 130
San Diego, CA 92122
Medi-Cal Contract Drug Advisory Committee
Prescription Price Updating Michael B. Huff, M.D.
314 West Fourth St.
EDS
Oxnard, CA 93030
P. O. Box 13029
Sacramento, CA 95813-4029
916/636-1000

6-California National Pharmaceutical Council


Pharmaceutical Benefits 2000

William B. Ness, M.D.


65 North 14th Street
San Jose, CA 95112

Gary M. McCart, Pharm.D.


University of California
School of Pharmacy
Division of Clinical Pharmacy
Box 0622
San Francisco, CA 94143-0622

Adrian M. Wong, Pharm.D.


17 Warren Drive
San Francisco, CA 94131
415/731-6239

Richard H. White, M.D.


U.C. California, Davis
Division of General Medicine
Primary Care Center, Room 3107
2221 Stockton Blvd.
Sacramento, CA 95817

Shirley Ann Floyd


131 Chester Ave., Suite A
Bakersfield, CA 93301

Executive Officers of State Medical and


Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
P.O. Box 7690
San Francisco, CA 94120-7690
415/541-0900

Osteopathic Physicians & Surgeons of California


Gary A. Gramm. D.O.
Executive Director
1900 Point West Way, Suite 188
Sacramento, CA 95815-4703
916/561-0724

California Pharmacists’ Association


Carlo Michelotti, R.Ph., M.P.H.
Chief Executive Officer
1112 I Street, Suite 300
Sacramento, CA 95814-2865
T: 916/444-7811
F: 916/443-1915

State Board of Pharmacy


Patricia F. Harris
Executive Officer
400 R Street, #4070
Sacramento, CA 95814
916/445-5014

National Pharmaceutical Council California-7


Pharmaceutical Benefits 2000

COLORADO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services    
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $110,159,725 147,033

CATEGORICALLY NEEDY, RECEIVING


ASSISTANCE, TOTAL
Aged
Blind/Disabled
AFDC-Children
AFDC-Adult
AFDC-Unemployed-Children
AFDC-Unemployed-Adults

MEDICALLY NEEDY, TOTAL


Aged
Blind/Disabled
AFDC-Children
AFDC-Adult

POVERTY RELATED, TOTAL


Aged
Blind/Disabled
AFDC-Children
AFDC-Adults

OTHER, TOTAL

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2000

Prior Authorization: State currently has a formal prior


C. ADMINISTRATION authorization procedure. There is an appeal process and
re-review when appealing coverage of an excluded
Eligibility is determined by 63 County Departments of product and prior authorization decisions.
Social Services, and the Colorado Department of Health
Care Policy and Financing administers the drug program. Prescribing or Dispensing Limitations

D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limit: New prescriptions for chronic or
acute conditions are prescribed at the discretion of the
Benefit Design physician. However, reasonable amounts for more than a
30-day supply for chronic conditions are recommended.
Drug Benefit Product Coverage: Products covered: Maximum supply is 100 days for maintenance medication
prescribed insulin. Products covered with restriction:
disposable needles and syringe combinations used for Drug Utilization Review
insulin; blood glucose test strips; urine ketone test strips,
total parenteral nutrition; and interdialytic parenteral PRODUR system implemented in December 1998.
nutrition. Products not covered: cosmetics; DESI drugs;
fertility drugs; prescribed vitamins (except prenatal); and Lock-In Review Procedures: The Department receives
experimental drugs. computer processed printouts designed to discover over-
utilization of drugs prescribed by physicians, dispensed by
Over-the-Counter Product Coverage: Products covered vendors, and received by eligible recipients.
with restriction: analgesics (ASA only); cough and cold
preparations (except >21) and smoking deterrent products. Pharmacy Payment and Patient Cost Sharing
Products not covered: allergy, asthma and sinus products;
digestive products (non-H2 antagonist); digestive products Dispensing fee: $4.08 as of July 1, 1990. Institutional
(H2 antagonist); feminine products; and topical products. pharmacies will receive a dispensing fee equal to $1.89.
Dispensing physicians shall not receive a dispensing fee
Therapeutic Category Coverage: Therapeutic categories unless their offices or sites of practice are located more
covered: analgesics, antipyretics, NSAIDs; antibiotics; than 25 miles from the nearest participating pharmacy. In
anticoagulants; anticonvulsants; antidepressants; the latter case, physicians receive a fee equal to $1.89.
antidiabetic agents; antihistamine drugs; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and Ingredient Reimbursement Basis: EAC = AWP-10% or
hypnotics; cardiac drugs; chemotherapy agents (given in WAC (wholesaler acquisition cost) + 18%. Other: FUL,
home); contraceptives; ENT anti-inflammatory agents; state Mac, usual and customary.
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents. Prescription Charge Formula: Benefit drugs shall be
Therapeutic categories partially covered: anorectics. Prior reimbursed at the lesser of the Medicaid allowable
authorization required for: anabolic steroids; prescribed reimbursement charge, or the provider’s usual and
cough and cold medication; growth hormones; vitamins; customary charge or whatever is accepted from any third
sexual dysfunction; Epogen; brand name and FUL drugs; party, discounts, rebates, etc.
and prescribed smoking deterrents.
The Medicaid allowable reimbursement charge is the sum
Coverage of Injectables: Injectable medicines of the ingredient cost of the drug dispensed and the
reimbursable through the Prescription Drug Program provider’s dispensing fee.
when used in home health care, extended care facilities
and through physician payment when used in physician Ingredient cost for retail pharmacies (estimated
offices. acquisition cost) is the price of the drug actually dispensed
as defined below or the MAC or the high volume EAC,
Vaccines: Vaccines reimbursable as part of the Vaccines whichever is less.
for Children Program.
The ingredient cost for institutional and government
Unit Dose: Unit dose packaging not reimbursable. pharmacies is defined as the actual cost of acquisition for
the drug dispensed or the MAC, or the high volume EAC,
Formulary/Prior Authorization whichever is less.

Formulary: Closed formulary Maximum Allowable Cost: The state MAC is the
maximum ingredient cost allowed by the Department for

National Pharmaceutical Council Colorado-2


Pharmaceutical Benefits 2000

certain multiple-source drugs. The establishment of a (1) The average wholesale price as it appears in the Red
MAC is subject, but not limited to, the following Book, its supplements, and Medi-Span will be the first
considerations: source. However, if there is a difference between the two
published average wholesale prices, the Department will
(1) Multiple manufacturers;
set the price as the published amount which is the closest
(2) Broad wholesale price span;
to the lowest average price charged by two drug
(3) Availability of drugs to retailers at the selected cost;
wholesalers doing business in Colorado.
(4) High volume of Medicaid recipient utilization;
(5) Bioequivalence or interchangeability.
(2) If there is a price change which does not appear
When federal MAC limits for multiple source drugs are immediately in the Red Book, its supplements, or in Medi-
announced, they will be adopted if they are less than state Span, then the Department will set the average wholesale
MACs or if no state MACs exist. price by averaging the wholesale prices of three drug
wholesalers doing business in Colorado, until the price is
The ingredient cost of any drug subject to MAC shall be published in the Red Book, its supplements, or in Medi-
limited to MAC or wholesale price as determined by the Span.
Department, whichever is less. Exceptions that will allow
reimbursement greater than MAC for a drug entity are (3) If the prices or changes do not appear in the
obtained through a prior authorization mechanism. An publications or the wholesalers’ records, then the
exception will be granted if the patient’s response to the distributors’ or manufacturers’ prices will be adjusted to
generic drug is not therapeutic, an allergic reaction is the wholesale pricing level and used in the drug pricing
involved, or any similar situation exists. file as the price of the drug.

If a recipient requests a brand name for a prescription that If the difference between the pharmacist’s invoice
is subject to MAC, then he/she may pay the ingredient purchase price and the average wholesale price which
cost difference between the MAC and brand name drug. appears in the Red Book, its supplements, or Medi-Span
The recipient must sign the prescription stating that he/she exceeds 18%, then the Department may adopt a lower
is willing to pay the difference in ingredient cost to the price after a survey is conducted to determine the validity
pharmacy. The pharmacy will be paid MAC plus a of the published prices. The price from the distributor or
dispensing fee or reimbursement charges, whichever is manufacturer will be adjusted the same as in 3 above.
lower.
Special Note: The Maximum Allowable Cost shall be
High volume Estimated Acquisition Cost (EAC): determined by the Division of Medical Assistance, based
Reimbursement for single source drugs or certain multiple upon professional determination of a quality product
source drugs which are most frequently prescribed will be available at the least expense possible.
based upon average wholesale prices (AWP) minus 10%,
or direct manufacturers’ prices for package sizes Exceptions to the above are:
containing quantities greater than 100 dosage units or less
if not available in 100’s. - Shelf package size oral liquid medications, in pint size
only, or smaller package size when not packaged in pint
Basis for inclusion in the high volume estimated size.
acquisition cost list includes but is not limited to: - Shelf package size oral tablet and capsule medications
(1) Single source manufacturers; in quantities of 100 only or smaller when not available in
(2) High volume Medicaid recipient utilization; package size of 100.
(3) Interchangeability problems with multiple source - Prescriptions for less than minimum amounts will be
drugs; denied reimbursement of the professional fee unless the
(4) Package sizes in excess of 100. physician notified the Department in writing of the
Drug Pricing: The Department will maintain a drug- medical need for amounts less than a 30-day supply.
pricing file that will be updated at least monthly. The Medical consultation determines the decision.
average wholesale price of a drug as determined by the
Incentive Fee: None.
Department, MAC, and high volume EAC, will be the
basis for setting the prices in the drug pricing file.
Patient Cost Sharing: Copay is $2.00 for brand name
products and $0.50 for generic.
The Department will determine the average wholesale
price that will be placed in the drug-pricing file as
Cognitive Services: Does not pay for cognitive services.
follows:

3-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2000

DUR Contact
E. USE OF MANAGED CARE
Allen Chapman, 303/886-3176
Approximately 210,000 total unduplicated number of
Medicaid recipients were enrolled in MCOs in FY 1999. Prescription Price Updating
Recipients receive pharmaceutical benefits through
managed care plans. Allen Chapman, 303/886-3176

Managed Care Organizations Medicaid Drug Rebate Contacts


Total Long-term Care Technical: Vince Sherry, 303/866-5408
303 East 17th Avenue Suite 650 DUR & PA: Allen Chapman, 303/866-3176
Denver, Colorado 80203
303/896-4664 Claims Submission Contact
Consultec, Inc.
HMO Colorado
600 17th Street
700 Broadway
Suite 600 North
Denver, Colorado 80273
Denver CO 80203
303/831-2374
800/237-0757
Kaiser Permanente
10350 East Dakota Avenue Medicaid Managed Care Contact
Denver, Colorado 80905
Gary Snider
303/344-7250
Director Managed Care Contractor
Department of Health Care Policy and Financing
Rocky Mountain HMO
1575 Sherman Street, 5th Floor
2775 Crossroads boulevard
Denver, CO 80203
Grand Junction, Colorado 81506
T: 303/886-3163
800/843-0719
F: 303/866-2573
Colorado Access
600 South Cherry STREET Suite 800 Physician-Administered Drug Program Contact
Denver, Colorado 80222
Patti Campbell
303/-355-6707
303/866-5459
Community Health Plan of the Rockies
400 South Colorado Boulevard Suite 300 Health Care Policy & Financing Department
Denver, Colorado 80222 Officials
303/355-3220
James T. Rizzato, Executive Director
Richard Allen, Director Health Plan and Medical Services
United Healthcare
6251 Greenwood Plaza Blvd, Suite 200
Office of Medical Assistance
Englewood, Colorado 80111-4910
Colorado Department of Health Care Policy & Financing
303/267/3594
1575 Sherman Street
Denver, Colorado 80203
F. STATE CONTACTS
Medical Advisory Council
Medicaid Drug Program Administrator
Donald W. Schiff, M.D.
Allen Chapman, R.Ph., M.S. 600 Front Range Road
Department of Health Care Policy and Financing Littleton, CO 80120
1575 Sherman Street, 5th Floor 303/837-2745
Denver, CO 80203
T: 303/886-3176 Molly A. Markert
F: 303/866-2573 11060 E. Wesley Pl.
Aurora, CO 80014
303/756-7234

National Pharmaceutical Council Colorado-4


Pharmaceutical Benefits 2000

Mary Jo Jacobs, M.D. Robert Slay


7425 E. Kenyon Ave. Jefferson Co. CCB
Denver, CO 80237 7456 W. 5th Avenue
303/694-2878 Lakewood, CO 80226
303/233-3363 x366
Walter Daniels, D.D.S.
1633 Filmore Street Department Contact
Denver, CO 80206 Richard Allen, Director
303/388-0989 Health Plans and Medical Services
303/866-6092
Rodney Fair, O.D.
105 Bridge Street Legislative Liaison
Brighton, CO 80601 Dean Woodward
303/659-3036 Department of Health Care Policy and Financing
303/866-2708
Douglas Clinkscales
Denver Health and Hospitals
Executive Officers of State Medical and
777 Bannock Street
Pharmaceutical Societies
Denver, CO 80204
303/426-7253 Colorado Medical Society
Sandra Mahoney
Cathy Corcoran Executive Vice President
15920 W. 66th Place 7800 E. Dorado Pl.
Golden, CO 80403 Englewood, CO 80111-2306
303/861-6256 303/779-5455

Ernestine Kotthoff-Burrell Colorado Pharmaceutical Association


6098 S. Iola Ct. Val Kalnins
Englewood, CO 80111 5150 East Yale Circle, Suite 304
303/270-8974 Englewood, CO 80112-1360
303/756-3069
Carol Bartley
Denver VNA Colorado Society of Osteopathic Medicine
3801 E. Florida Ave., Suite 800 Kathleen Brennan
Denver, CO 80201 Executive Director
303/753-7312 50 S. Steele Street, Suite 770
Denver, CO 80209
Mary Ellen Kuhlman, MSW 303/322-1752
St. Mary’s Hospital & Medical Center
P.O. Box 1628 State Board of Pharmacy
Grand Junction, CO 81502 Kent Mount
970/244-2273 Program Administration
1560 Broadway, Suite 1310
Dan Stenerson Denver, CO 80202-5146
Shalom Park 303/894-7750
14800 E. Belleview
Aurora, CO 80015 Colorado Hospital Association
303/680-5000 Larry Wall
President
Mark Kunart, D.O. 2140 South Holly St.
17200 E. Iliff Avenue Denver, CO 80222-5607
Aurora, CO 80013 303/758-1630
303/755-4111

5-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2000

CONNECTICUT

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs          
Inpatient Hospital Care          
Outpatient Hospital Care          
Laboratory & X-ray Service          
Skilled Nursing Home Services          
Physician Services          
Dental Services          
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $186,593,992 108,331

CATEGORICALLY NEEDY, RECEIVING


ASSISTANCE, TOTAL
Aged
Blind/Disabled
Child
Adult
Unemployed Parent-Child
Unemployed Parent-Adult

MEDICALLY NEEDY, TOTAL


Aged
Blind/Disabled
Child
Adult

POVERTY RELATED, TOTAL


Aged
Blind/Disabled
Child
Adult

OTHER, TOTAL

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council Connecticut-1


Pharmaceutical Benefits 2000

C. ADMINISTRATION Formulary/Prior Authorization

State of Connecticut Department of Social Services through Formulary: Open formulary, however, the following
five regional offices and nine sub-offices. products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility drugs;
D. PROVISIONS RELATING TO DRUGS smoking cessation products; DESI drugs, and drugs
available free from the Department of Health Services.
Benefit Design
Prior Authorization: State currently has no prior
Drug Benefit Product Coverage: Products covered: authorization procedure.
prescribed insulin, disposable needles and syringe
combinations for insulin; blood glucose test strips; urine Prescribing or Dispensing Limitations
ketone test strips; total parenteral nutrition (except in
NH); and interdialytic parenteral nutrition (except in NH). Prescription Refill Limit: 6-month refill limit except for
Products not covered: cosmetics; fertility drugs; and oral contraceptives, which have a 12-month limit.
experimental drugs. Controlled substances have a 5 refill or 6-month limit.

Over-the-Counter Product Coverage: Products covered: Monthly Quantity Limit: Maximum 240 tablets or
digestive products (non-H2 antagonists); feminine capsules. Oral contraceptives: 3 months supply may be
products; analgesics; and cough and cold preparations dispensed at one time.
(children < 19 years). Products not covered: smoking Physicians are encouraged to prescribe drugs generically,
deterrent products; allergy, asthma and sinus products; when possible.
digestive products (H2 antagonists); topical products;
iron; calcium; oral contraceptives; and some trace Drug Utilization Review
elements. For nursing home patients, the department will
not pay for OTC drugs used in nursing facilities (such drugs PRODUR system implemented September 1996. Retro
are covered in the per diem rate). Some drugs require DUR since September 1991; the state currently has a
diagnosis for reimbursement such as CNS stimulants for DUR Board with a quarterly review.
ADD and narcolepsy. Pharmacy Payment and Patient Cost Sharing
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, Dispensing Fee: $4.10, effective 1/1/91.
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Ingredient Reimbursement Basis: EAC = AWP-12%.
antilipemic agents; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Prescription Charge Formula: Federal MAC or EAC plus
medications; contraceptives; ENT anti-inflammatory dispensing fee; or usual and customary if lower.
agents; estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); thyroid agents; and Maximum Allowable Cost: State imposes Federal Upper
growth hormones. Therapeutic categories not covered: Limits on generic drugs. Override requires “Brand
anorectics and prescribed smoking deterrents. Medically Necessary.”

Coverage of Injectables: Injectable medicines reimbursable Incentive Fee: The Department will pay an incentive
through the Prescription Drug Program when used in home professional dispensing fee of $0.50 per prescription, in
health care, extended care facilities, and through physician addition to any other dispensing fee, for substituting a
payment when used in physicians offices. No injectable generically equivalent drug product.
drug list.
Patient Cost Sharing: None.
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program. Cognitive Services: Does not pay for cognitive services.

Unit Dose: Unit dose packaging not reimbursable. E. USE OF MANAGED CARE

Connecticut has approximately 230,000 Medicaid recipients


enrolled in managed care and receive pharmaceutical
benefits.

2-Connecticut National Pharmaceutical Council


Pharmaceutical Benefits 2000

Michael Starkowski, Deputy Commissioner


Managed Care Organizations
860/424-5053
Blue Cross / Blue Shield of CT
Blue Care Family Plan David Parrella, Director
John Brangi, Director Medical Administration Policy
Medicaid Managed Care 203/424-5116
370 Bassett Road
North Haven, CT 06473-4201 Michelle Parsons, Manager
203/985-6464 Alternate Care Unit
860/951-9544 203/424-5177

Community Health Network of CT James Linnane, Manager


290 Pratt - 2nd Floor Benefit Design Unit
Meriden, CT 06450 203/424-5111
203/237-4000
Marcia Mains, Manager
PHS Healthy Options Medical Operations
Janice Perkins, Assistant VP 203/424-5219
Government Relations and Programs
One Far Mill Crossing, Box 904
DUR Contact
Shelton, CT 06484-0944
203/239-7444 x664 Elizabeth A. Geary, R.Ph.
860/424-5150
HealthChoice of CT
Preferred One
Connecticut DUR Board
Sylvia Kelley, VP, Executive Director
23 Maiden Lane Kenneth Fisher R.Ph.
North Haven, CT 06473 Brooks Pharmacy
203/239-7444 x664
(withdrawing from program as of 4th quarter of 2000) Arturo Morales M.D.
St. Francis Hospital
860/714-2976
F. STATE CONTACTS
Lori Jane Duntz Lord R.Ph.
Medicaid Drug Program Administrator Greenville Drug
Elizabeth A. Geary, R.Ph. 860/889-9857
Health Program Supervisor
Dept. of Social Services Jeffrey J. Messina R.Ph.
25 Sigourney Street Fort Hill Pharmacy
Hartford, CT 06106 860/445-6431
T: 860/424-5150
F: 860/951-9544 Rick Carbray, R.Ph.
E-mail: elizabeth.geary@po.state.ct.us 16 Beacon Street
Newington, CT 06111
860/529-6305
Department of Social Services Administrative
Officials Frederick N. Rowland, M.D.
Patricia A. Wilson-Coker St. Francis Hospital and Medical Center
Commissioner 860/679-2281
Dept. of Social Services
25 Sigourney St. Dennis Chapron, R.Ph., M.S.
Hartford, CT 06016-5033 UConn Health Center
860/679-2281
Rita Pacheco, Deputy Commissioner
203/424-5055

National Pharmaceutical Council Connecticut-3


Pharmaceutical Benefits 2000

Cynthia Huge, R.Ph. Connecticut Pharmacists Association


Lexicon Pharmacy Services Margherita R. Guiliano, R.Ph. Executive V.P.
800/233-7873 35 Cold Spring Road, Ste. 124
800/342-4980 Rocky Hill, CT 06067-3100
203/563-4619
Prescription Price Updating
Osteopathic Medical Society
Lynne Freiburger-Epstein, D.O.
First Data Bank
Secretary/Treasurer
225 Main Street
Medicaid Drug Rebate Contacts Manchester, CT 06040
Elizabeth Geary 860/645-7014
Medical Operations
860/424-5150 State Board of Pharmacy
Ellen Arce, R.Ph., 860/832-5885 (Audits) Michelle Sylvestre, R.Ph.
Board Administrator
State Office Building, Room G-1A
Claims Submission Contact Hartford, CT 06106
Twila Smith 203/566-3290
EDS Federal Corp.
100 Stanley Drive Connecticut Hospital Association, Inc.
New Britain, CT 06053 Dennis P. May
860/832-5800 President
110 Barnes Road
P.O. Box 90
Medicaid Managed Care Contact Wallingford, CT 06492-0090
James Gaito 203/294-7202
Department of Social Services
25 Signourney St. Prescription Price Adjustments and Updates
Hartford, CT 06106
860/424-5137 First Data Bank-Blue Book
E-mail: james.gaito@po.state.ct.us

Elderly Drug Coverage Program Contact


Elizabeth Geary
860/424-5150

Physician-Administered Drug Program Contact


Zanita McKinney, Medical Policy
25 Sigourney Street
Hartford, CT 06106
860/424-535

State Pharmacy Commission


William Summa, P.D., Chairman

Executive Officers of State Medical and


Pharmaceutical Societies
State Medical Society
Timothy B. Norbeck, Executive Director
160 St. Ronan Street
New Haven, CT 06511
203/865-0587

4-Connecticut National Pharmaceutical Council


Pharmaceutical Benefits 2000

DELAWARE

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services    
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $41,350,537 69,027

RECEIVING CASH ASSISTANCE, TOTAL


Aged
Blind/Disabled
AFDC-Children
AFDC-Adult
AFDC-Unemployed-Children
AFDC-Unemployed-Adults

MEDICALLY NEEDY, TOTAL


Aged
Blind/Disabled
AFDC-Children
AFDC-Adult

POVERTY RELATED, TOTAL


Aged
Blind/Disabled
AFDC-Children
AFDC-Adults

OTHER, TOTAL

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council Delaware-1


Pharmaceutical Benefits 2000

C. ADMINISTRATION Prescribing or Dispensing Limitations


Prescription Refills: Prescription blank has space for
Division of Social Services, Department of Health and physician to authorize renewals.
Social Services, through three county offices of the state
agency. Monthly Quantity Limit: Greater of 34-day supply or 100
dosing units.
D. PROVISIONS RELATING TO DRUGS
Monthly Dollar Limits: None.
Benefit Design
Drug Utilization Review
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe PRODUR system implemented in August 1994.
combinations used for insulin; blood glucose test strips;
urine ketone test strips; and total parenteral nutrition. Pharmacy Payment and Patient Cost Sharing
Products not covered: cosmetics; fertility drugs;
experimental drugs; and interdialytic parenteral nutrition. Dispensing Fee: $3.65.

Over-the-Counter Product Coverage: Products covered: Ingredient Reimbursement Basis: EAC = AWP-12.9%.
allergy, asthma and sinus products; analgesics; cough and
cold preparations; digestive products (non-H2 antagonist); Prescription Charge Formula: Payment is based on
digestive products (H2 antagonists); and smoking AWP-12.9% or maximum allowable cost (MAC) plus a
deterrent products. Products covered with restriction: dispensing fee, or the usual and customary cost to the
feminine products (antifungals) and topical products (anti- general public, whichever is lower.
infectants).
Maximum Allowable Cost: State imposes Federal Upper
Therapeutic Category Coverage: Therapeutic categories Limits as well as state-specific limits on generic drugs.
covered: anabolic steroids; analgesics, antipyretics, State-specific MAC list contains 90 drugs. Override
NSAIDs; antibiotics; anticoagulants; anticonvulsants; requires “Brand Medically Necessary.”
antidepressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Incentive Fee: None.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Patient Cost Sharing: None.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; prescribed smoking deterrents; Cognitive Services: Does not pay for cognitive services.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: anorectics and growth E. USE OF MANAGED CARE
hormones.
Approximately 68,000 total unduplicated number of
Coverage of Injectables: Injectable medicines Medicaid recipients were enrolled in MCOs in FY 1999.
reimbursable through the Prescription Drug Program and Recipients receive pharmaceutical benefits through the
physician payment when used in physician offices. state.
Reimbursable only through the Prescription Drug Program
when used in extended care facilities. Managed Care Organizations
DelawareCare
Vaccines: Vaccines reimbursable under the Vaccines for
2751 Centerville Road, Suite 400
Children program.
Wilmington, DE 19808
215/937-8285
Unit Dose: Unit dose packaging not reimbursable. No
price based on AWP.
First State Health Plan
1801 Rockland Road, Suite 300
Formulary/Prior Authorization
Wilmington, DE 19803
302/576-7603
Formulary: Open formulary.

Prior Authorization: State currently has a formal prior


authorization procedure.

2-Delaware National Pharmaceutical Council


Pharmaceutical Benefits 2000
Carl Mulveny
F. STATE CONTACTS 1941 Limestone Rd.
Wilmington, DE 19808
State Drug Program Administrator
Phile Soulé Michael Glacken
Delaware Health and Social Services 500 West 10th St.
1901 N. Dupont Highway Wilmington, DE 19801
New Castle, DE 19720
T: 302/577-4900 Prescription Price Updating
F: 302/577-4405 Cynthia Denemark , 302/453-8453
Agency Internet Address:
http://www.state.de.us/govern/agencies/dhss Medicaid Drug Rebate Contacts
Prior Authorization Contact Technical: Ralph Dominica, 302/454-7622
Policy: E. Beth Laucius, 302/577-4902
Cynthia Denemark Dispute Resolution: Jessica Bullion, 302/454-7622
Pharmacist Consultant
EDS Claims Submission Contact
248 Chapman Road, Suite 200
Newark, DE 197029720 Thomas Ignudo
T: 302/453-8453 Account Manager
F: 302/454-7603 EDS
E-mail: cynthia.denemark@eds.com 248 Chapman Rd
Newark, DE 19702
DUR Contact
Physician-Administered Drug Program Contact
Cynthia Denemark , 302/453-8453
Cynthia Denemark , 302/453-8453
DUR Board
Health and Social Services Department Officials
Calvin Freedman, R.Ph.
302 Lark Drive Secretary
Newark, DE 19713-1216 Dept. of Health & Social Services
Delaware State Hospital
Marvin H. Dorph, M.D. New Castle, DE 19720
614 Loveville Road 302/577-4500
Unit E4H Coffee Run Condo
Hockessin, DE 19707 Philip P. Soulé, Sr.
Deputy Director, Medicaid
Daniel M. Hauser, Pharm.D. 302/577-4901
325 W. Broadstair
Dover, DE 19904 Dr. James B. Salva
Medical Consultant
Victoria Paoletti 302/577-4900
153 Owenwood Dr.
Lincoln University, PA 19352 Medical Advisory Committee Members
Edward R. Sobel, D.O.
Richard Steele
1100 S. Broom Street
2617 Epping Rd.
Wilmington, DE 19805
Wilmington, DE 19810
Anne Aldridge, M.D.
Marcus Wilson, Pharm.D.
671 Clifton Dr.
29 Peninsula Court
Bear, DE 19701
Bear, DE 19701
Sister Jeanne Cashman, O.S.U.
Sharon Wisneski, R.N., M.S.
Ursuline Academy Convent
336 Pine Valley Road
1104 Pennsylvania Avenue
Dover, DE 19901
Wilmington, DE 19806

National Pharmaceutical Council Delaware-3


Pharmaceutical Benefits 2000
Neil McLaughlin George English
Fernhook Community Mental Health Blue Cross Blue Shield of DE
14 Central Avenue One Brandywine Plaza
New Castle, DE 19720 Wilmington, DE 19899

Richard Cherrin Micheal Glacken, M.D.


Visiting Nurses Association Medical Director
New Castle Corporate Commons Connections, CSP
One Reads Way 500 West 10th St.
New Castle, DE 19720 Wilmington, DE 19801

Steven A. Dowshen, M.D. Daniese McMullin-Powell


A.I. duPont Institute A.D.A.P.T
P.O. Box 269 24 S. Old Baltimore Pike
Wilmington, DE 19899 Newark, DE 19702

Bob Welch Leonard Nitowski, M.D.


Bureau Health Planning & Resource Management Doctors for Emergency Services
Jesse Cooper Building, Suite 160 PO Box 3048
Dover, DE 19901 Wilmington, DE 19804

John A. Forrest, Jr., M.D. Julia M. Pillsbury, D.O.


195 Lynnhaven Drive Center for Pediatric and Adolescent Medicine
Dover, DE 19904 125-1 Greentree Drive
Dover, DE 19904
Mark Meister
Medical Society of Delaware Ulder Jane Tillman, M.D.
1925 Lovering Avenue Jesse Cooper Building
Wilmington, DE 19806 417 Federal and Water Streets
Dover, DE 19901
Olga Ramirez
Community Legal Aid Society, Inc. Yrene E. Waldron
913 Washington Street Executive Director
Wilmington, DE 19801 DE Health Care Facilities Association
Two Mill Rd., Suite 200
Penny D. Chelucci Wilmington, DE 19806
De Counsel on Gambling Problems
100 W. 10th Street Executive Officers of State Medical and
Community Service Bldg., Suite 303 Pharmaceutical Societies
Wilmington, DE 19801
Medical Society of Delaware
Mark Meister, Sr.
Joseph Letnaunchyn
Executive Director
Delaware Health Care Association
1925 Lovering Avenue
1280 S. Governor’s Avenue
Wilmington, DE 19806
Dover, DE 19901
302/658-7596
David Allen Delaware Pharmaceutical Society
Vice President Martin Golden
Ambulatory & Continuing Care Services Executive Director
Milford Memorial Hospital Tindell Square Professional Plaza
21 W. Clark Ave. 1601 Milltown Road, Suite 8
Milford, DE 19963 Wilmington, DE 19808
302/892-2880

4-Delaware National Pharmaceutical Council


Pharmaceutical Benefits 2000

Osteopathic Medical Society


Edward Sobel, D.O.
Executive Secretary
P. O. Box 845
Wilmington, DE 19899
302/475-6881

State Board of Pharmacy


David Dryden, R.Ph., J.D.
Executive Secretary
Cooper Building
Federal and Water Streets
Dover, DE 19901
302/739-4708

Association of Delaware Hospitals


Joseph M. Letnaunchyn
President
1280 South Governors Avenue
Dover, DE 19904-4802
302/674-2853

National Pharmaceutical Council Delaware-5


Pharmaceutical Benefits 2000

DISTRICT OF COLUMBIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs         
Inpatient Hospital Care         
Outpatient Hospital Care         
Laboratory & X-ray Service         
Skilled Nursing Home Services         
Physician Services         
Dental Services     
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $41,254,973 57,733

CATEGORICALLY NEEDY CASH TOTAL


Aged
Blind
Disabled
Children - Families w/Dep. Children
Adults - Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTAL


Aged
Blind
Disabled
Children - Families w/Dep. Children
Adults - Families w/Dep. Children
Other Title XIX Recipients

MEDICALLY NEEDY TOTAL


Aged
Blind
Disabled
Children - Families w/Dep. Children
Adults - Families w/Dep. Children
Other Title XIX Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-District of Columbia National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Pharmacy Payment and Patient Cost Sharing

The District of Columbia Department of Health (DOH), Dispensing Fee: $3.75.


Medical Assistance Administration.
Ingredient Reimbursement Basis: AWP - 10%.
D. PROVISIONS RELATING TO DRUGS
Prescription Charge Formula: The lesser of: Upper limit
Benefit Design established by HCFA or the AWP - 10% plus the
dispensing fee or usual and customary to the public.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Maximum Allowable Cost: State imposes Federal Upper
combinations used for insulin; and ferrous sulfate. Prior Limits on generic drugs. Override requires “Brand
authorization required for: injectable drugs administered Medically Necessary” with explanation.
on an outpatient basis; anorexic drugs for treatment of
narcolepsy and minimal brain dysfunction in children; Incentive Fee: None.
acute anti-ulcer drugs, and brand NSAIDS. Products not
covered: all other non-legend items. Patient Cost Sharing: $1.00 copay by recipient. Does not
apply to recipients under 18, prescriptions for family
Over-the-counter Product Coverage: Products covered: planning, nursing home patients, or pregnancy related.
oral analgesics; oral antacids; contraceptive foams and
jellies; prenatal vitamin formulations; geriatric vitamin Cognitive Services: Does not pay for cognitive services.
formulations for recipients 65 and over; and multivitamin
formulations for children 7 years of age and over. E. USE OF MANAGED CARE

Coverage of Injectables: Injectable medicines Recipients enrolled in managed care receive


reimbursable when used in physicians offices, home pharmaceutical benefits through managed care plans.
health care, and extended care facilities.
Managed Care Organizations
Vaccines: Vaccines reimbursable at cost as part of the
Advantage Health Plan, Inc.
EPSDT service.
P.O. Box 9596
Washington, DC 20016
Unit Dose: Unit dose packaging not reimbursable
202/686-8555
Formulary/Prior Authorization American Preferred Provider Plan Mid-Atlantic, Inc.
1501 M Street, NW, Suite 500
Formulary: Open formulary Washington, DC 20002
202/408-0460
Prescribing or Dispensing Limitations

Monthly Quantity Limit: In general, amounts dispensed D.C. Chartered Health Plan
are to be limited to quantities sufficient to treat an episode 820 First Street, NE, Ste. LL100
of illness. Maintenance drugs such as thyroid, digitalis, Washington, DC 20002
etc. may be dispensed in amounts up to a 30-day supply 202/408-4710
with 3 refills that must be dispensed within 4 months.
Antibiotic medications used in treatment of acute Capitol Community Health Plan
infections are not to be dispensed in excess of a 10-day 750 First Street, NE, Ste. 1120
supply. Birth control tablets may be dispensed in 3-cycle Washington, DC 20002
units with a maximum of 3 refills within one year. 202/408-0460

Monthly Dollar Limits: $1,500 limit. Physicians are to George Washington University Health Plan
request prior authorization for prescriptions that exceed 4550 Montgomery Avenue
this amount. Beheads, MD 20814
301/941-2044
Drug Utilization Review

PRODUR system implemented in September 1996.

National Pharmaceutical Council District of Columbia-2


Pharmaceutical Benefits 2000

Health Right, Inc. Physician-Administered Drug Program Contact


3020 14th Street, NW
Donna Bovell
Washington, DC 20009
202/727-0753
202/518-2370
Prudential Health Care Plan
Department of Human Services Officials
2800 N. Charles Street
Baltimore, MD 21218 Geraldine Williams
410/554-7224 Director
Department of Human Services
2700 MLK Avenue, SE
F. STATE CONTACTS (801 East Bldg.)
Washington, DC 20023
State Drug Program Administrator
Donna Bowel Marlene Kelly, M.D.
Pharmacist Consultant Acting Director
Commission on Health Care Finance Department of Health
2100 M.L. King Jr. Ave. SE 1660 L Street, NW
Suite 302 12th Floor
Washington, DC 20020 Washington, DC 20002
202/727-0753
Paul Offner
Deputy Director, DOH
District of Columbia DUR Board Medical Assistance Administration
Christopher Keeyes, Pharm.D. (Chair) 2100 M.L. King Jr. Ave. SE
President, Clinical Pharmacy Associates Suite 302
11710 Beltsville Drive, Suite 510 Washington, DC 20020
Calberton, MD 20705
301/572-1616 Executive Officers of District Medical and
Pharmaceutical Societies
Martin Dillard, M.D. (Vice Chair)
Assistant Dean for Clinical Affairs Medical Society of the District of Columbia
Chief, Division of Nephrology K. Edward Shanbacker
Howard University Hospital 2215 M St., NW
2041 Georgia Avenue, NW, Suite 5C02 Washington, DC 20037-2059
Washington, DC 20060 202/466-1800
202/865-1191
Pharmaceutical Association
Howard Robinson, R.Ph. Herbert Kwash, R.Ph., President
Manager, Central Pharmacy 6406 Georgia Ave, NW
Greater Community Hospital Washington, DC 20012
1310 Southern Avenue, SE 202/829-1515
Washington, DC 20032
Osteopathic Association
Dr. Kim Bullock Roy Heaton, D.O., Secretary
Providence Hospital 4001 N. 9th Street, Suite 216
Emergency Room Arlington, VA 22203
1150 Varuum St., NE 703/522-8404
Washington, DC 20017
202/269-7863 DC Board of Pharmacy
Cheryl A. Robinson, Chair
614 H Street N.W., Rm. 904
Medicaid Drug Rebate Contacts Washington, DC 20001
Technical: Ken Boni, 202/965-7400 202/727-7468
Policy: Donna Bovell, 202/727-0753
DUR: Donna Bovell, 202/727-0753

3-District of Columbia National Pharmaceutical Council


Pharmaceutical Benefits 2000

District of Columbia Hospital Association


Robert Malson, President
1250 Eye Street, NW, Suite 700
Washington, DC 20005-3980
202/682-1581

Fiscal Intermediary
Jack Zaelo
First Health Services, Inc.
122 C Street, N. W.
Washington, DC 20001
202/783-5610

National Pharmaceutical Council District of Columbia-4


Pharmaceutical Benefits 2000

FLORIDA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs         
Inpatient Hospital Care         
Outpatient Hospital Care         
Laboratory & X-ray Service         
Skilled Nursing Home Services   
Physician Services         
Dental Services  
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999
Expended Recipients Expended Recipients
TOTAL $933,782,041 1,014,372 $1,089,866,582 982,886

RECEIVING CASH ASSISTANCE, TOTAL $710,423,515 555,823


Aged $126,584,312 76,097
Blind / Disabled $509,397,909 212,404
AFDC-Child $26,292,425 151,467
AFDC-Adult $36,189,923 69,409
AFDC-Unemployed-Child $4,312,209 25,383
AFDC-Unemployed-Adult $7,646,737 21,063

MEDICALLY NEEDY, TOTAL $46,363,601 19,024


Aged $62,129 20
Blind / Disabled $38,021,526 8,395
AFDC-Child $2,782,675 3,521
AFDC-Adult $5,497,271 7,088

POVERTY RELATED, TOTAL $193,659,597 282,166


Aged $71,343,167 45,811
Blind / Disabled $93,785,943 36,579
AFDC-Child $22,471,261 145,201
AFDC-Adult $6,059,226 54,575

OTHER $139,419,869 125,873

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.
C. ADMINISTRATION

Agency for Health Care Administration. Claims


processing and payment by contract with fiscal agent.

1-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2000

D. PROVISIONS RELATING TO DRUGS 3. Non-legend drugs (except for prescribed insulin,


pancreatic enzymes, buffered and enteric coated
Benefit Design aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
Drug Benefit Product Coverage: Products covered: 4. Anorexants unless the drug is prescribed for an
prescribed insulin; disposable needles and syringe indication other than obesity (i.e. narcolepsy,
combinations used for insulin; blood glucose test strips; hyperkinesis).
total parenteral nutrition; and urine ketone test strips for 5. Drugs with questionable efficacy as rated by FDA
children under age 21. Prior authorization required for: (DESI).
Cytogam; Proleukin; Serostim; Albumin; Neutrexin; 6. Investigational and experimental items.
Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; 7. Oral vitamins with exception of fluorinated pediatric
Regranex (long term care); Botox; and nutritional vitamins prescribed for pediatric patients, vitamins
supplements. Products not covered: cosmetics; fertility for dialysis patients, prenatal vitamins.
drugs; experimental drugs; and interdialytic parenteral 8. Smoking cessation products only to EPSDT clients
nutrition. under age 21.
9. Nursing home floor stock drugs.
Over-the-Counter Product Coverage: Products covered:
smoking deterrents; allergy, asthma and sinus medication Prior Authorization: State currently has a formal prior
(limited); analgesics (aspirin); cough and cold authorization procedure. An appeal hearing request is
preparations (only children under 21 years); feminine required to appeal prior authorization decisions.
products (prior Rx only); iron supplements; Guaifenesin;
and vaginal antifungals. Products not covered: digestive Prescribing or Dispensing Limitations
products (H2 antagonists) and topical products.
Prescription Refill Limit:
Therapeutic Category Coverage: Therapeutic categories 1. Six (6) prescriptions monthly for community patients;
covered: anabolic steroids; analgesics, antipyretics, 8 prescriptions per month for institutionalized
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti- patients. Increased grants are available based on need
depressants; antidiabetic agents; antipsychotics; and diagnosis.
anxiolytics, sedatives, and hypnotics; cardiac drugs; 2. Maintenance medication should be dispensed and
chemotherapy agents; contraceptives; ENT anti- billed for at least a one-month supply.
inflammatory agents; estrogens; hypotensive agents; misc. 3. Refills must be authorized by the prescriber and can
GI drugs; prescribed smoking deterrents (only children be made for up to one year, except that controlled
under 21 years); sympathominetics (adrenergic); and substances can be refilled only in accordance with
thyroid agents. Prior authorization required for: growth federal and state regulations.
hormones. Therapeutic categories not covered: 4. Anti-ulcer, anti-anxiety, and sedative hypnotic drugs
anorectics. limited to 1 per therapeutic class per month, 1 refill
per prescription.
Coverage of Injectables: Injectable medicines 5. Nutritional supplements are covered with prior
reimbursable through the Prescription Drug Program authorization when the patient is otherwise at risk of
when used in home health care and extended care hospitalization.
facilities, and through physician payment when used in 6. Other third parties, including Medicare, must be
physician offices. billed first
Vaccines: Vaccines reimbursable as part of the Vaccines
for Children Program.

Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization

Formulary: Open formulary with the following limits and


exclusions.
1. Vitamins and phosphate binders only for dialysis
patients.
2. Prostheses; appliances; devices; and personal care
items.

National Pharmaceutical Council Florida-2


Pharmaceutical Benefits 2000

Florida 1st Health Plans, Inc.


Drug Utilization Review
Contact: Frank Willis
3425 Lake Alfred Road
PRODUR system implemented in July 1994. State
Winter Haven, FL 33881
currently has a DUR board with a quarterly review.
941/293-0785
Retrospective Drug Utilization Review has been in place
since 1982. The state Medicaid agency and the Florida
Foundation Health,
Pharmacy Association, which performs the reviews, share
A Florida Health Plan, Inc.
the administration of the program.
Contact: Michael Comerford
1340 Concord Terrace
Pharmacy Payment and Patient Cost Sharing Sunrise, FL 33323
800/422-7335
Dispensing Fee: $4.23, effective 3/11/86.
Healthease
Ingredient Reimbursement Basis: AWP-13.25 %. Contact: Christopher O’Connor
6800 N. Dale Mabry Hwy., Suite 168
Prescription Charge Formula: Lower of: Tampa, FL 33614-3988
1. FUL (Federal Upper Limits or State MAC) plus 813/290-6358
dispensing fee.
2. EAC plus dispensing fee. Healthy Palm Beaches, Inc.
3. Usual and customary charge.
4. In-house unit dose diff. + 0.015/dose. Humana Family
Contact: Patricia L. Hubrig
Maximum Allowable Cost: State imposes Federal Upper c/o Humana Medical Plan, Inc.
Limits and State Specific Limits on generic drugs. 3400 Lakeside Drive, 5th Floor
Provisions for MAC override by physicians only if listed Miramar, FL 33027
on negative formulary. 305/626-5616
Incentive Fee: No incentive fee. Jackson Memorial Health Plan
Contact: Taryn Davis
Patient Cost Sharing: No copayment 1801 NW 9th Ave., Suite 700
Miami, FL 33136
Cognitive Services: Does not pay for cognitive services. 305/575-3700

E. USE OF MANAGED CARE MedChoice Health Plan


Contact: Jeffery G. Keiser
All Medicaid recipients receive pharmaceutical benefits 5300 West Atlantic Avenue
through managed care plans (inclusion of such benefits is Delray Beach, FL 33484-8190
mandated under state law). 561/496-0505

Managed Care Organizations Neighborhood Health Partnership, Inc.


Alpha Health Plan, Inc. Contact: Heidi Etzold
7600 Corporate Center Dr., Suite 300
Beacon Health Plans, Inc. Miami, Fl 33126-1216
Contact: Ana M. Berenguer 305/715-4318
2511 Ponce de Leon Blvd., 5th Floor
Coral Gables, FL 33134 Personal Health Plan
305/774-2599 Contact: Debi L. Gavras
Dr. Jeff Davis, D.O. (Interim)
Discovery Plan 324 Datura Street, Suite 401
Contact: Robert Wychulis West Palm Beach, FL 33401
3520 Thomasville Road, Suite 200 561/659-1270 ext. 5885
Tallahassee, FL 32308
850/894-0100 ext. 801

3-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2000

Physicians Healthcare Plans, Inc.


Prior Authorization Contact
Contact: Peter Jimenez
2333 Ponce de Leon Blvd. Ste 303 Linda Anthony, R.Ph.
Coral Gables, FL 33134 Senior Pharmacist
305/441-9400 ext. 125 Agency for Health Care Administration
2727 Mahan Drive
Preferred Medical Plan, Inc. Tallahassee, FL 32308
Contact: Tamara Meyerson T: 850/922-0679
4950 SW 8th Street F: 850/922-0685
Coral Gables, FL 33134
305/445-8373 DUR Contact
Coordinator: Marie Donnelly-Stephens
St. Augustine Health Care, Inc.
Senior Health Care Program Analyst
Contact: Mary Lynn Leach
Agency for Health Care Administration
Mail: P.O. Box 23160
2727 Mahan Drive
Location: 4300 NW 89th Blvd.
Tallahassee, FL 32308
Gainesville, FL 32606
T: 850/487-4441
352/337-8650
F: 850/922-0685
Stay Well Health Plan
Contact: Nancy Gareau Medicaid DUR Board
6800 N. Dale Mabry Hwy., Ste. 209-211
Tampa, FL 33614 Matthew Cohen, M.D.
813/290-6283 Bryan A. Bognar, M.D.
David B. Levine, D.P.M., D.O.
United Healthcare of Florida, Inc. Richard Roberts, Pharm.D.
Contact: Linna Van Nette Michael Thompson, Pharm.D.
800 North Magnolia Ave., Suite 600 Earlene E. Lipowski, Ph.D.
Orlando, FL 32803 Mechelle LaWarre, Pharm.D.
407/872-1000 Larry L. Mattingly, D.O.
L. Leanne Lai, Ph.D.
United ElderCare Plan Lynn G. Massey, Pharm.D.
800 N. Magnolia Ave., #600
Orlando, FL 32803 Program Retro-DUR
800/643-5337
Gaylon Fruit, R.Ph.
Director Retro DUR Program
F. STATE CONTACTS
Prescribing Pattern Review Panel
State Drug Program Administrator
J. David Moore, M.D.
Jerry F. Wells
Walter Flesner, D.O.
Pharmacy Program Manager
Daryl D. Wier, M.D.
Agency for Health Care Administration
Mary Stelnicki, R.Ph.
2727 Mahan Drive, MS 38
Stephen Clark, M.D.
Tallahassee, FL 32308
Dennis Penzell, D.O.
T: 850/487-4441
B.L. Stalnaker, M.D.
F: 850/922-0685
Cynthia Griffin, Pharm.D.
E-mail: wellsj@fdhc.state.fl.us

Prescription Price Updating


Agency for Health Care Administration Officials
Ruben J. King-Shaw, Jr., Director First Data Bank
Agency for Health Care Administration
Gary Crayton, Director for Medicaid
850/488-3560

National Pharmaceutical Council Florida-4


Pharmaceutical Benefits 2000

S. Shai Gold,
Medicaid Drug Rebate Contacts
Director, Business and Proposal Development Center
Technical: Ralph Quinn, 850/488-9190 The South Florida Community Care Network
Policy: Jerry Wells, 850/487-4441 1801 NW 9th Avenue, Ste 700
Audits: Jerry Wells, 850/487-4441 Miami, FL 33136
Disputes: Greg Bracko, 850/488-9193 T: 305/585-5187
F: 305/585-3815
E-mail: umimbdc@compusource.net
Claims Submission Contact
Mark Steck Diabetes:
PBM Director Virginia M. Dollar
Consultec, Inc. Coordinated Care Solutions
9040 Roswell Road, Suite 700 210 N. University Drive, Ste 700
Atlanta, GA 30350 Coral Springs, FL 33071
770/594-7799 T: 954/344-2444
F: 954/796-3688
Medicaid Managed Care Contact Asthma:
Ralph Anderson, R.N. ITG (program sponsor)
Agency for Health Care Administration
2727 Mahan Drive, BLD 1, Rm 323 Plans exist for disease management programs for End-
Tallahassee, FL 32308 Stage Renal Disease (ESRD) and congestive heart failure.
T: 850/487-0640 Contact: Bob Sharpe
F: 850/414-5418 Assistant Deputy Director for Medicaid
Agency for Health Care Administration
2727 Mahan Drive
Disease Management Program/Initiative Contact Tallahassee, FL 32308
850/488-3560
Hemophilia:
Michael L. Ansel
Accordant Health Services Physician-Administered Drug Program
5509-A West Friendly Avenue, Ste 101 Laura Rutledge
Greensboro, NC 27410 850/488-4481
T: 336/855-5870 ext.134
F: 336/852-7413
E-mail: mansel@accordant.com Executive Officers of State Medical and
Pharmaceutical Societies
George E. Hurrell, Jr.
Florida Medical Association, Inc.
Director, Disease Management
Charles S. Amorosino, Jr.
Caremark Inc.
P.O. Box 10269
1127 Bryn Mawr Avenue
123 S. Adams St.
Redlands, CA 92374
Tallahassee, FL 32301
T: 909/799-4160
904/224-6496
F: 909/7998-4335
E-mail: george.hurrell@mdmnetwork.com
Florida Pharmacy Association
Michael Jackson, R.Ph.
AIDS:
Executive Vice President
Peter D. Reis
610 North Adams Street
Director of Business Development
Tallahassee, FL 32301
AIDS Healthcare Foundation
850/222-2400
6255 West Sunset Blvd, 16th Fl.
Los Angeles, CA 90028
Florida Osteopathic Medical Association
T: 213/860-5200
Larry Mattingly, D.O.
F: 213/860-5235
2007 Apalachee Parkway
E-mail: pdreisjr@aol.com
The Hull Building
Tallahassee, FL 32301
850/878-7364

5-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2000

State Board of Pharmacy


John Taylor
Executive Director
NorthWood Center
1940 North Monroe Street, Suite 60
Tallahassee, FL 32399-0775
850/488-7546

Florida Hospital Association


Charles F. Pierce, Jr.
President
307 Park Lake Circle
P.O. Box 531107
Orlando, FL 32853-1107
407/841-6230

National Pharmaceutical Council Florida-6


Pharmaceutical Benefits 2000

GEORGIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN)* Other
OAA AB APTD AFDC OAA AB APTD AFDC** Children <21 SFO
Prescribed Drugs      
Inpatient Hospital Care      
Outpatient Hospital Care      
Laboratory & X-ray Service      
Skilled Nursing Home Services      
Physician Services      
Dental Services      
1
See Appendix E, page E-29, for a list of acronyms.
*Aged, Blind & Disabled (all services) effective April, 1990
**Pregnant Women Only

B. EXPENDITURES FOR DRUGS


1998 1999*
Expended Recipients Expended Recipients
TOTAL $370,562,935 805,923

CATEGORICALLY NEEDY CASH TOTAL $242,900,444 344,678


Aged $36,834,592 38,041
Blind/Disabled $177,559,013 151,138
Children-Families w/Dep. Children $14,661,159 108,295
Adults-Families w/Dep. Children $13,845,680 47,204

CATEGORICALLY NEEDY NON-CASH TOTAL $41,423,040 330,361


Aged $804,074 1,409
Blind/Disabled $787,847 926
Children-Families w/Dep. Children $32,698,175 257,296
Adults-Families w/Dep. Children $7,132,944 70,730
Other Title XIX Recipients $0 0

MEDICALLY NEEDY TOTAL $740,135 458


Aged $75,378 57
Blind/Disabled $657,789 372
Children-Families w/Dep. Children $6,968 29
Adults-Families w/Dep. Children $0 0
Other Title XIX Recipients $0 0

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable
.

1-Georgia National Pharmaceutical Council


Pharmaceutical Benefits 2000

Unit Dose: Unit dose packaging reimbursable.


C. ADMINISTRATION
Formulary/Prior Authorization
Department of Community Health, Division of Medicaid
Formulary: Closed formulary.
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal prior
Benefit Design authorization procedure

Drug Benefit Product Coverage: Products covered: Prescribing or Dispensing Limitations:


prescribed insulin; prescribed disposable needles; and
syringe combinations for insulin. Products covered with Prescription Refill Limit: Maximum of five refills for
restrictions: blood glucose test strips (100 per month); adults, six for children
urine ketone test strips (100 per month); total parenteral
nutrition (21 and younger); and interdialytic parenteral Monthly Quantity Limit: Physicians are encouraged to
nutrition (21 and younger). Products requiring prior prescribe a 31-day supply.
authorization: Marinol; Epoetin; interferons; lactulose;
neupogen; acutretin; top.vit.A derivatives; blood factors; Monthly Dollar Limit: $1000, followed by manual review.
toradol; H2RA full dose > 2months; Regranex; Viagra;
PPIs; Sucralfate full dose after 2 months; brand names and Drug Utilization Review
multi-source; and hemophilia clotting factors. Products
not covered: cosmetics; fertility drugs; experimental On-line PRODUR system implementation planned with a
drugs; prescription vitamins and minerals (except for Sept.1, 2000 start date. State currently has a DUR Board
prenatal and fluorides not in combination with other under development.
vitamins); barbituates (except Seconal); DESI drugs; and
Miralax. Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Products covered: Dispensing Fee: $4.63, effective 7/1/98.
analgesics (Ibuprofen suspension) covered with restriction
for ages less than 21; cough and cold preparations; PIN- Ingredient Reimbursement Basis: EAC = AWP - 10%.
X; NIX; iron; and meclizine. Products not covered:
digestive products; feminine products; topical products; Prescription Charge Formula: Lower of average
and smoking deterrent products. wholesale price (AWP) minus 10% plus dispensing fee,
MAC plus fee, or usual and customary.
Therapeutic Category Coverage: Therapeutic Categories
Covered: antibiotics; anticoagulants; anticonvulsants; Maximum Allowable Cost: State imposes Federal Upper
antidepressants; antidiabetic agents; antilipemic agents; Limits and State Specific Limits on generic drugs.
antipsychotics; cardiac drugs; chemotherapy agents; Override requires “Brand Medically Necessary.”
contraceptives; ENT anti-inflammatory agents; estrogens; Approximately 55 drugs on the state-specific MAC list.
hypotensive agents; misc. GI drugs; sympathominetics
(andrenergic); and thyroid agents. Prior authorization
Incentive Fee: None.
required for: anabolic steroids; analgesics, antipyretics,
NSAIDS for single source; anorectics; antihistamine drugs
Patient Cost Sharing: $0.50 per prescription copayment
for non-sedating >21yo; anxiolytics, sedatives, and
(branded or generic).
hypnotics; growth hormones; and immunoglobulins.
Therapeutic categories not covered: prescribed smoking
Cognitive Services: Does not pay for cognitive services.
deterrents.

Coverage of Injectables: Injectable medicines E. USE OF MANAGED CARE


reimbursable through the Prescription Drug Program
when used in home health care, extended care facilities, Does not use MCOs to deliver services to Medicaid
and through physician payment when used in physicians recipients. Program discontinued October 1999.
offices.

Vaccines: Vaccines reimbursable as part of the EPSDT


service, Children Health Insurance Program, and as part
of the Vaccines for Children Programs.

National Pharmaceutical Council Georgia-2


Pharmaceutical Benefits 2000

Catherine E. Burley, M.D., Chairperson


F. STATE CONTACTS 7365 Old National Hwy, Ste A
Riverdale, GA 30296
State Drug Program Administrator
Etta L. Hawkins, R.Ph. Hal J. Henderson, R.Ph.
Department of Community Health-Medical Division Medical Arts Health Care
2 Peachtree Street, 37th Floor 1483-B Milstead Ave.
Atlanta, GA 30303-3159 Conyers, GA 30012
T: 404/657-7239
F: 404/656-8366 Randall T. Maret, R.Ph.
E-mail: ehawkins@dch.state.ga.us Vice Chairperson
Agency Internet Address: http://www.state.ga.us/dch Maret’s Prescription Shop
222 N. Pentz Street
Department of Community Health Dalton, GA 30720

Russ Toal, Commissioner J. Russell May, Pharm.D.


Department of Community Health Department of Pharmacy
2 Peachtree Street Medical College of Georgia
Atlanta, GA 30303-3159 Hospital and Clinics
404/656-4479 1120 15th Street
Augusta, GA 30912-5600
Herb Weldon, Deputy Commissioner
Bill Connell, Interim Director A. Thomas Taylor, Pharm.D.
Div. of Professional Services Medical College of Georgia
Dona Cole, Director College of Pharmacy
Division of Acute Car Department of Family Medicine
2 Peachtree Street 4799 Hereford Farm Road
Atlanta, GA 30303-3159 Evans, GA 30809

Earl S. Ward, Pharm.D.


Prior Authorization Contact Mercer University School of Pharmacy
Jean Cox, R.Ph. 3001 Mercer University Drive
DUR/PA Coordinator Atlanta, GA 30341
DCH Medicaid
2 Peachtree Street, 37th floor Gary C. Richter, M.D,
Atlanta, GA 30303-3159 Consultative Gastroenterology
T: 404/657-7241 121 Linden Avenue, Suite 103
F: 404/656-8366 Atlanta, GA 30308
E-mail: jcox@dch.state.ga.us
Norman C. Moore, M.D.
Brain Research Center
DUR Contact 655 First Street
Jean Cox, 404/657-7241 Macon, GA 31201

Medicaid DUR Board John Dorland Rowlett, M.D.


John Stephen Antalis, M.D. Children’s Hospital at Memorial Medical Center
Dalton Family Practice, P.C. PO Box 23089
1114 Professional Blvd. Savannah, GA 31403
Dalton, GA 30720
Term: 7/1/97-6/30/99 J.Grady Strom, Jr. Ph.D.
Mercer University School of Pharmacy
Edwin D. Bransome, Jr., M.D. 3001 Mercer University Drive
Department of Medicine Atlanta, GA 30341-4155
Room BIW-542
Medical College of Georgia Harry Strothers, M.D.
Augusta, GA 30912-3185 505 Fairburn Rd. S.W.
Atlanta, GA 30331

3-Georgia National Pharmaceutical Council


Pharmaceutical Benefits 2000

Reuben S. Roberts, Jr., M.D.


Medical Assistance Advisory Committees
Pulaski Professional Building
P.O. Drawer 1237 Representatives from each of the following groups:
Hawkinsville, GA 31036 Medical Association of Georgia
Georgia Pharmaceutical Association
Prescription Price Updating Atlanta Medical Association
Georgia Health Care Association
Etta L. Hawkins, 404/657-7239 Georgia Hospital Association
Georgia Dental Association
Georgia Osteopathic Medical Association
Medicaid Drug Rebate Contacts
National Pharmaceutical Association
Policy: Susan Oh, 404/657-9181
PA: First Health Services, 770/916-9269 Executive Officers of State Medical and
Audits: Susan Oh, 404/657-9181 Pharmaceutical Societies
Claims Submission Contact
Medical Association of Georgia
Cheryl Collier Paul Shanor
Account Manager, EDS Executive Director
736 Park North Blvd 938 Peachtree Street, N. E.
P.O. Box 736 Atlanta, GA 30309
Clarkston, GA 30021 404/876-7535
T: 404/297-3700
F: 404/298-1031 Georgia Pharmaceutical Association
Oren “Buddy” Harden
Medicaid Managed Care Contact Executive Vice President
20 Lenox Pointe, P.O. Box 95527
Kathy Driggers Atlanta, GA 30347
Director, Managed Care 404/231-5074
Department of Community Health
2 Peachtree Street, N.W. Osteopathic Medical Association
Atlanta, Georgia 30303 Jerome E. Mersberger, D.O.
T: 404/657-7793 Secretary/Treasurer
F: 404/656-8366 2160 Idlewood Road
E-mail: kdriggers@dch.state.ga.us Tucker, GA 30084
770/493-9278
Disease Management Program/Initiative Contact State Board of Pharmacy
Mark Trail Gregg W. Schuder
Director of Program Policy Executive Director
Department of Community Health- Medicaid 166 Pryor Street, SW
2 Peachtree Street, N.W. Atlanta, GA 30303
Atlanta, Georgia 30303 404/656-3912
T: 404/657-1502
F: 404/656-8366 Medical Georgia Association
E-mail: mtrail@dch.state.ga.us Katherine Daniels
Executive Director
Morehouse School of Medicine
Physician-Administered Drug Program Contact 720 Westview Drive, S.W.
Shirley Benson Atlanta, GA 30310-1495
2 Peachtree Street, N.E. 404/752-1564
Atlanta, Georgia 30303
404/656-3961 Georgia Hospital Association
Joseph A. Parker
President
1675 Terrell Mill Road
Marietta, GA 30067
770/955-5801

National Pharmaceutical Council Georgia-4


Pharmaceutical Benefits 2000

HAWAII

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs          
Inpatient Hospital Care          
Outpatient Hospital Care          
Laboratory & X-ray Service          
Skilled Nursing Home Services          
Physician Services          
Dental Services          
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $39,623,380 32,222

CATEGORICALLY NEEDY CASH TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

MEDICALLY NEEDY TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

Source: HHS Report HCFA-2082.


‡This group accounts for the Aged, Blind and Disabled population only. 130,000 recipients are in managed care. Expenditures
for prescribed drugs total $250,000,000 and are included in the capitation rate.
*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Hawaii National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Prescribing or Dispensing Limitations

By the State Department of Human Services through its Quantity of Medication: Physicians are encouraged to
Med-Quest Division and four county branch offices. prescribe a 30-day supply or 100 units.

D. PROVISIONS RELATING TO DRUGS Drug Utilization Review

Benefit Design PRODUR system implemented in September 1997. State


currently has a DUR board with a quarterly review.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Pharmacy Payment and Patient Cost Sharing
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and Dispensing Fee: $4.67, effective May 9, 1990.
interdialytic parenteral nutrition. Products requiring prior
authorization: Clorazil; Procardia XL; Norvasc; brand Ingredient Reimbursement Basis: EAC = AWP - 10.5%.
products on FUL price list; and Betaseron. Products not
covered: cosmetics; fertility drugs; and experimental Prescription Charge Formula: Payment for prescription
drugs. and OTC drugs listed in the formulary is limited to the
federally established MAC price, or Estimated
Over-the-Counter Product Coverage: Products covered: Acquisition Cost (EAC) plus dispensing fee, or billed
some allergy, asthma and sinus products; some analgesics; amount, whichever is lowest.
some cough and cold preparations; digestive products;
some feminine products; and some topical products. Maximum Allowable Cost: State imposes Federal Upper
Products covered with restrictions: some non-H2 Limits on generic drugs. Override requires “Brand
antagonist digestive products and H2 antagonist digestive Medically Necessary” and “Dispense As Written” as well
products (requires diagnosis of H. Pylori, GERD, etc.). as prior authorization approval. Exclusions: anti-seizure
Products not covered: smoking deterrent products. medication and oral contraceptives.

Therapeutic Category Coverage: Prior authorization Incentive Fee: None.


required for: anabolic steroids; anorectics; antihistamine
drugs; anti-psychotics; anxiolytics, sedatives, and Patient Cost Sharing: No copayment.
hypnotics; estrogens; misc. GI drugs; prescribed smoking
deterrents; proton pump inhibitors; single source NSAIDs; Cognitive Services: Does not pay for cognitive services.
chemotherapy agents; and growth hormones.
E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines
reimbursable through the prescription drug program when Approximately 140,000 total unduplicated number of
used in home health care, extended care facilities, and Medicaid recipients were enrolled in MCOs in FY 1999.
through physician payment when used in physicians Recipients receive pharmaceutical benefits through
offices. state/managed care plans or both.

Vaccines: Vaccines reimbursable as part of EPSDT Managed Care Organizations


service if not covered by the Vaccines for Children
DentiCare
Program.
Wesley K.S. Mun
900 Fort Street Mall, Suite 930
Unit Dose: Unit dose packaging reimbursable
Honolulu, HI 96813
808/528-4904
Formulary/Prior Authorization
Hawaii Medical Service Association (HMSA)
Formulary: Open formulary.
Ms. Carolyn J. Gire, Director
QUEST Administration
Prior Authorization: State currently has a formal prior
818 Keeaumoku Street
authorization procedure. A fair hearing may be requested
Honolulu, HI 96808
for appeal of prior authorization decisions.
808/948-6588

National Pharmaceutical Council Hawaii-2


Pharmaceutical Benefits 2000

Queen’s Hawaii Care DUR Contact


Mr. Richard M. Jackson, General Manager
Kathleen Kang-Kaulupali, 808/692-8115
Two Waterfront Plaza
500 Ala Moana Boulevard
Honolulu, HI 96813 Medicaid DUR Board
808/522-7522
Myron Shirasu, M.D. (Internal Medicine)
321 North Kuakini Street #200
Straub Clinic and Hospital, Inc.
Honolulu, HI 96817
Deborah Stampfle, Executive Director
808/523-8611
641 Kailua Road
Kailua, HI 96734 Tube 63
Gregory E.M. Yuen, M.D. (Psychiatry)
808/266-6554
Chair
1154 Fort Street Mall, Suite 200
AlohaCare, Inc.
Honolulu, HI 96813
Mr. John McComas
808/599-5050
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
Linda Tom MD (Geriatric Medicine)
808/973-1650
347 N. Kuakini Street, HPM-9
Honolulu, HI 96817
Kaiser Foundation Health Plan, Inc.
808/523-8461
Ms. Virginia Vierra
1441 Kapliolani Blvd, Suite 1600
James Lumeng, M.D. (Medicine/Pathology)
Honolulu, HI 96814
850 West Hind Drive, #114
808/944-0261
Honolulu, HI 96821
808/377-5485
Kapliolani Health Hawaii
Plan Administrator: Greg Oishi
Brian Matsuura (Medical Services Rep.)
55 Merchant Street, 27th Floor
864 Kealahou St.
Honolulu, HI 96813-4306
Honolulu, HI 96825
808/535-7425
808/396-3974
Behavioral Health Services
Joy Higa, R.Ph. (Long Term Care)
Community Care Services (CCS)
47-135 Heno Place
Sharon Yoshiura or Carolyn Gire
Kaneohe, HI 96744
810 N. Vineyard Blvd.
808/239-6353
Honolulu, HI 96817
T: 808/ 948-5379
Karen Huang, R.Ph. (Ambulatory Care)
F: 808/948-6588
1010 Pensacola Street
Honolulu, HI 96814
F. STATE CONTACTS F: 808/597-2549
Pager: 808/363-0838
Medicaid Drug Program Administrator
Kerry Kitsu, R.Ph. (Community, chain)
Lynn Donovan, R.Ph. 98-629 Nohoalii Street
Medicaid Pharmacy Consultant Aiea, HI 96701
Med-Quest Division T: 808/536-5542
P.O. Box 339 F: 808/536-0659
Honolulu, HI 96809-0339
T: 808/692-8116 Carl Mudrick, R.Ph. (Community, independent)
F: 808/692-8131 2011 Coyne Street
Honolulu. HI 96826
Prior Authorization Contact T: 808/739-1188
F: 808/735-6545
Lynn S. Donovan
808/692-8116

3-Hawaii National Pharmaceutical Council


Pharmaceutical Benefits 2000

State Board of Pharmacy


Prescription Price Updating
Ruth Gushiken
First Data Bank Executive Secretary
111 Bayhill Dr. P. O. Box 3469
San Bruno, CA 94066 Honolulu, HI 96801
800/633-3453 808/586-2698

Healthcare Association of Hawaii


Medicaid Drug Rebate Contacts
Richard E. Meiers
Technical: Lynn Donovan, 808/692-8116 Pres., CEO
Policy: Lynn Donovan, 808/692-8116 932 Ward Avenue
Audits: Lynn Donovan, 808/692-8116 Suite 430
DUR: Kathleen Kang-Kaulupali, 808/692-8115 Honolulu, HI 96814-2126
808/521-8961
Claims Submission Contact
HMSA - Medicaid Claims Service
Attn: Luukia Abbley
P.O. Box 860
Honolulu, HI 96808
808/948-5361

Department of Human Services Officials


Susan M. Chandler, Director
Department of Human Services
808/586-4997

Chuck Duarte
Administrator, Med-Quest Division

Executive Officers of State Medical and


Pharmaceutical Societies
Hawaii Medical Association
Stephanie Averio, Executive Director
1360 S. Beretania Street, Suite 100
Honolulu, HI 96814
808/536-7702

Hawaii Pharmaceutical Association


Todd Inafuku, R.Ph.
Executive Director
P. O. Box 1198
Honolulu, HI 96807
808/941-8321

Association of Osteopathic Physicians and Surgeons


Alan R. Becker, D.O.
Secretary/Treasurer
122 Oneawa Street
Kailua, HI 96734
808/261-6105

National Pharmaceutical Council Hawaii-4


Pharmaceutical Benefits 2000

IDAHO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services 
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998 1999*
Expended Recipients Expended Recipients
TOTAL $54,971,097 86,775

RECEIVING CASH ASSISTANCE, TOTAL $15,699,226 11,194


Aged $2,228,943 1,434
Blind / Disabled $12,543,258 6,397
AFDC-Child $254,663 2,098
AFDC-Adult $669,332 1,231
AFDC-Unemployed-Child $501 10
AFDC-Unemployed-Adult $2,529 24

MEDICALLY NEEDY, TOTAL $0 0


Aged $0 0
Blind / Disabled $0 0
AFDC-Child $0 0
AFDC-Adult $0 0

POVERTY RELATED, TOTAL $26,669,496 26,219


Aged $14,394,179 8,038
Blind / Disabled $12,703,668 8,035
AFDC-Child $857,649 6,575
AFDC-Adult $1,714,000 3,571

OTHER $5,318,605 37,215

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Idaho National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure and a Growth hormone prior
Idaho Medicaid Agency authorization committee. Written “notice of appeal”
required for fair hearing.
By the State Department of Health and Welfare through
seven regional offices, each serves five or more of the Prescribing or Dispensing Limitations
State’s 44 counties.
Monthly Quantity Limit: Prescription drugs are limited to
D. PROVISIONS RELATING TO DRUGS a 34-day supply. The following drugs are limited to a 100-
day supply: Digoxin, thyroids, prenatal vitamins,
Benefit Design nitroglycerin, fluoride, fluoride and vitamin combinations,
non-legend oral iron salts and 3 cycles of birth control.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Drug Utilization Review
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and Contracted DUR through Idaho State University.
interdialytic parenteral nutrition. Products not covered: PRODUR system implemented January 1998. State
cosmetics; fertility drugs; and experimental drugs. currently has a DUR board with a quarterly review.

OTC Coverage: Products covered: prescribed insulin; Pharmacy Payment and Patient Cost Sharing
disposable needles and syringe combinations used for
insulin; permethrin; and oral iron salts. Products not Dispensing Fee: $4.94 ($5.54 for unit dose), effective
covered: allergy, asthma, and sinus; analgesics, cough and March 1999.
cold preparations; digestive products; feminine products;
topical products; and smoking deterrent products. Ingredient Reimbursement Basis: EAC = AWP-11% as
determined by First DataBank Data File Service or
Therapeutic Category Coverage: Therapeutic Categories manufacturer direct price for selected manufacturers.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Prescription Charge Formula: Lower of FUL, SMAC or
antidepressants; antidiabetic agents; antihistamine drugs; EAC plus a dispensing fee or provider’s usual and
antilipemic agents; anti-psychotics; anxiolytics, sedatives, customary price to the general public.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Maximum Allowable Cost: State imposes Federal Upper
inflammatory agents; estrogens; hypotensive agents; misc. Limits and state-specific limits on generic drugs. Override
GI drugs; sympathominetics (adrenergic); and thyroid requires prior authorization.
agents. Prior authorization required for: growth
hormones. Therapeutic categories not covered: anorectics Incentive Fee: None.
and prescribed smoking deterrents.
Patient Cost Sharing: No copayment.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Cognitive Services: Does not pay for cognitive services.
when used in home health care, extended care facilities,
and through physician payment when used in physicians
offices.
E. USE OF MANAGED CARE
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program, and the Vaccines for Children Does not use MCOs to deliver services to Medicaid
Program. recipients. Some Medicaid recipients are enrolled in
primary care case management and receive their benefits
Unit Dose: Unit dose packaging reimbursable when used from the state.
in unit dose systems.

Formulary Authorization

Formulary: Open formulary.

National Pharmaceutical Council Idaho-2


Pharmaceutical Benefits 2000

F. STATE CONTACTS Medicaid Managed Care Contact


Pam Mason
Medicaid Drug Program Administrator Primary Physician Managed Care Program
Gary Duerr, R.Ph. Healthy Connections Manager
Medicaid Policy P.O. Box 83720
Americana Terrace, Suite 140 Boise, ID 83720
P.O. Box 83720 T: 208/364-1890
Boise, ID 83720-0036 F: 208/364-1846
T: 208/364-1829 E-mail: masonpa@mmig.state.id.us
F: 208/364-1846
E-mail: duerrgp@mmis.state.id.us Physician-Administered Drug Program Contact
Robbie Charlton
Prior Authorization Contact Medicaid Policy
PO Box 83720
Gary Duerr, 208/364-1829 Boise, ID 83720-0036
DUR Contact
Health and Welfare Department Officials
Gary Duerr, 208/364-1829 Karl Kurtz, Director
Dept of Health & Welfare, Medicaid Division
Medicaid DUR Board Towers Building, 10th Floor
Board Members: PO Box 83720
Bill Johns, R.Ph. Boise, Idaho 83720-0036
Don Smith, R.Ph. 208/334-5500
Kent Jensen, R.Ph.
Barbara Wells, R.Ph. Bureau of Medicaid Policy and Reimbursement
John Lassere, M.D. Dee Anne Moore, Bureau Chief
E. Gregory Thompson, M.D. Joe Brunson, Medicaid Administration
Robert Ting, M.D. Gary Duerr, R.Ph., Pharmacy Services Specialist
Clayton Morgan, M.D., retired Tom Young, M.D., Medical Consultant

Staff: Title XIX Medical Care Advisory Committee


Gary Duerr, R.Ph., Dept. Contact
Vaughn Culbertson, Pharm.D. Project Dir. Bob Beutler
1217 Kirk Drive
Moscow, ID 83943
Prescription Price Updating 208/882-5536
First Data Bank
Rep. Max C. Black
3731 Buckingham Drive
Medicaid Drug Rebate Contacts Boise, ID 83704
Technical: Gary Duerr, R.Ph. 208/364-1829 208/327-3400
Policy: Gary Duerr, 208/364-1829
DUR: Gary Duerr, 208/ 364-1829 Marj Boren
PA: Gary Duerr, 208/ 364-1829 1002 E. Bannock
Audits: David Mendoza, 208/ 364-1838 Boise, ID 83712
208/342-4368

Claims Submission Contact Sen. Hal Bunderson


EDS 582 River Heights Drive
P.O. Box 1168 Meridian, ID 83642
Boise, ID 83701 208/888-7156
208/395-2000

3-Idaho National Pharmaceutical Council


Pharmaceutical Benefits 2000

Loni Debbon, President JoAn Silva, Director


Idaho Head Start Association Region III Health & Welfare
200 N. 4th 111 Poplar, PO Box 1219
Boise, ID 83702 Caldwell, ID 83606
208/345-1182 208/459-7456

Bonnie Haines, Senior Vice President Acting Executive Director


Idaho Hospital Association Idaho State Council on Developmental Disabilities
PO Box 1278 280 N. 8th, Suite 208 Statehouse
Boise, ID 83701-1278 Boise, ID 83720
208/338-5100 208/334-2178

Steven Hanson Scott Spears


Human Service Connection Idaho Health Care Association
1380 Benton PO Box 2623
Idaho Falls, ID 83401 Boise, ID 83701
208/523-2490 208/343-9735

Cathy Hart
Executive Officers of State Medical and
Idaho Office on Aging
Pharmaceutical Societies
Statehouse, Room 108
Boise, ID 83720-0007 Idaho Medical Association
208/334-3833 Robert Seehusen
Executive Director
Sally Higginson 305 West Jefferson, P.O. Box 2668
Boise Alliance for the Mentally Ill Boise, ID 83702
331 N. Allumbaugh 208/344-7888
Boise, ID 83704
208/376-4304 Idaho State Pharmaceutical Association
Jo An Condie
Shirley Osborn Executive Director
5553 W. Lockport 305 W. Jefferson, P.O. Box 140117
Boise, ID 83703 Boise, ID 83714
208/334-3110 208/424-1107

Jim Peart Idaho Osteopathic Medical Association


Idaho Legal Aid, Caldwell Area Office Ron Higgenbotham, D.O.
708 Main Street, PO Box 1116 Secretary-Treasurer
Caldwell, ID 83606-1116 522 West Main Street
208/345-2193 Grangeville, ID 83530
208/983-1133
Cathleen Pierson
3368 N. 34th Street State Board of Pharmacy
Boise, ID 83703 Richard K. Markuson
208/385-7305 Executive Director
3380 Americana Terrace #320
Rex Redden, President Boise, ID 83706
IACOR 208/334-2356
PO Box 50457
Idaho Falls, ID 83405 Idaho Hospital Association
208/523-0053 Steven A. Millard
President
Bob Seehusen, Executive Director 802 West Bannock St.
Idaho Medical Association Suite 500
305 W. Jefferson Boise, ID 83702-5842
Boise, ID 83702 208/338-5100
208/344-7888

National Pharmaceutical Council Idaho-4


Pharmaceutical Benefits 2000

ILLINOIS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs          
Inpatient Hospital Care          
Outpatient Hospital Care          
Laboratory & X-ray Service          
Skilled Nursing Home Services          
Physician Services          
Dental Services          
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $583,239,675 959,472

CATEGORICALLY NEEDY CASH TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children

CATEGORICALLY NEEDY NON-CASH TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

MEDICALLY NEEDY TOTAL


Aged
Blind
Disabled
Children-Families w/Dep. Children
Adults-Families w/Dep. Children
Other Title XIX Recipients

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2000

C. ADMINISTRATION Drug Utilization Review

Illinois Department of Public Aid, Division of Medical PRODUR system implemented in January 1993. State
Assistance. currently has a DUR board with a review on an as needed
basis.
D. PROVISIONS RELATING TO DRUGS
Pharmacy Payment and Patient Cost Sharing
Benefit Design
Dispensing Fee: $3.75/$3.45 for generic/branded drugs
Drug Benefit Product Coverage: Products covered: costing up to $37.50; 10.46% of the drug cost for drugs
prescribed insulin; disposable needles and syringe costing $37.51 and more; maximum of $15.70/$15.40 for
combinations used for insulin; blood glucose test strips; generic/branded drugs. Effective 7/1/99.
and urine ketone test strips. Products not covered:
cosmetics; DESI-ineffectives; fertility drugs; experimental Ingredient Reimbursement Basis: EAC = AWP - 10%,
drugs; total parenteral nutrition; and interdialytic AWP - 12% for multisource drugs.
parenteral nutrition.
Prescription Charge Formula: Lowest of 1) usual and
OTC Coverage: Products covered: digestive products (H2 customary, 2) Department's MAC plus fee. Professional
antagonists) and smoking deterrent products. Products fee: $3.58 up to EAC of $35.80; above EAC of $35.80,
requiring prior authorization: analgesics; digestive fee is 10% of EAC.
products (non-H2 antagonist); and topical products.
Products not covered: allergy, asthma, and sinus; cough Maximum Allowable Cost: State imposes Federal Upper
and cold preparations; and feminine products. Limits as well as state-specific limits on generic drugs.
All drugs are interchangeable in Illinois but not for those
Coverage of Injectables: Injectable medicines with a Federal MAC. Other drugs appear on the Illinois
reimbursable through the Prescription Drug Program MAC list where the Federal MAC was inappropriate.
when used in physician offices, home health care, and Override requires prior authorization.
extended care facilities.
Incentive Fee: None.
Vaccines: Vaccines are reimbursable as part of a special
program. Patient Cost Sharing: No copayment.

Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.

Formulary/Prior Authorization E. USE OF MANAGED CARE

Formulary: Closed formulary. Approximately 158,000 Medicaid recipients were


voluntarily enrolled in MCOs in 1999. Recipients receive
Prior Authorization: State currently has a formal prior pharmaceutical benefits through managed care plans.
authorization procedure and a Committee on Drugs and
Therapeutics. Recipient must file an appeal with their Managed Care Organizations
local office in order to appeal prior authorization Americaid Community Care
decisions. To appeal the coverage of an excluded product, 211 Wacker Drive
the recipient can request the opportunity to appear before Suite 1350
the Committee on Drugs and Therapeutics. Chicago, IL 60606-3101
Prescribing or Dispensing Limitations United Health Care of IL
233 N. Michigan Ave. 8th Fl-12th Fl.
Prescription Refill Limit: Maximum of eleven refills. Chicago, IL 60601
Monthly Quantity Limit: As medically appropriate. Harmony Health Plan of Illinois
125 South Wacker Drive
Suite 2900
Chicago, IL 60606-4402

National Pharmaceutical Council Illinois-2


Pharmaceutical Benefits 2000

Humana Health Plan


Medicaid Drug Rebate Contacts
30 South Wacker Drive
Suite 3100 Technical: Marvin Hazelwood, 217/524-7112
Chicago, IL 60606 Policy: Marvin Hazelwood, 217/524-7112
Audits: Alberta Levan, 217/782-5565
Illinois Masonic Community Health Plan Dispute Resolutions: Alberta Levan, 217/524-7161
836 West Wellington
Chicago, IL 60657-5147 Medicaid Managed Care Contact

Family Health Network Nelly Ryan


910 West Van Buren Bureau Chief
6th Floor Illinois Department of Public Aid
Chicago, IL 60607-3523 201 S. Grand Avenue East
Springfield, Illinois 62763
Neighborly Care Plan T: 217/524-7478
129 N. Eighth Street F: 217/524-7535
East St. Louis, IL 62201-2999
Elderly Expanded Drug Coverage Program
F. STATE CONTACTS Cheryl Payne
Supervisor, Circuit Breaker Program
State Drug Program Administrator Illinois Department of Revenue
Marvin L. Hazelwood 101 W. Jefferson - Level 3- 250
Illinois Department of Public Aid Springfield, Illinois 62794
Division of Medical Assistance 217/785-2097
1001 N. Walnut St.
Springfield, IL 62702
Physician-Administered Drug Program Contact
T: 217/524-7112
F: 217/524-7194 Cheryl Bechner
E-mail: aidd2958@mail.idpa.state.il.us 217/782-5565
Agency E-mail Address: http://www.state.il.us/dpa/
Illinois Medicaid Agency Officials
Prior Authorization Contact Ann Patla, DR.HL
Rick Mazzotti, R.Ph. Illinois Department of Public Aid
217/787-6252 Division of Medical Assistance
201 South Grand Avenue, East
Springfield, IL 62763-0001
DUR Contact 217/782-1200
Starlin Hayden Greatting, R.Ph.
Pharmacy Consultant, DUR coordinator Mary Ann Langston, Administrator
Illinois Department of Public Aid Division of Policy
1001 N. Walnut St.
Springfield, Illinois 62702 Norman L. Ryan, Administrator
T: 217/524-7112 Division of General Services
F: 217/524-7194
Kenneth J. Durst, Chief
Bureau of Research & Analysis
Prescription Price Updating
First Data Bank Matt Powers, Administrator
111 Bayhill Dr. Division of Medical Programs
San Bruno, CA 94066
Steve Bradley, Chief
Bureau of Comprehensive Health Services

3-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2000

Patty Steward, R.Ph., Pharmacist Consultant Joan E. Cummings, M.D.


Department of Public Aid Extended Care
P.O. Box 19117 181 Hines VA Hospital
Springfield, IL 62794-9117 Building 1, Room C-124D
217/782-5565 Hines, IL 60141
708/343-7200 ext. 5057
Title XIX Medical Care Advisory Committees
David B. Littman, M.D.
State Medical Advisory Committee 1030 Old Elm Road
Arthur Traugott, M.D. Highland Park, IL 60035
32207 Weisiger Way 708/433-3900
Urbana, IL 61801
Richard P. Snodgrass, M.D.
Committee on Drugs and Therapeutics 550 30th Avenue
Marshall Blankenship, M.D., Chairman Moline, IL 61265
1555 Astor Avenue 309/764-1910
Chicago, IL 60610
708/636-3757 IDPA Representative
Marvin Hazelwood
Nicholas C. Bellios, M.D. Illinois Department of Public Aid
2504 Washington 1001 N. Walnut St.
Waukegan, IL 60085 Springfield, IL 62702
708/249-3660 217/524-7112

Armand Littman, M.D. Illinois State Medical Society


Medical Services Kenneth E. Ryan
Hines VA Hospital Director, Department of Economics
Hines, IL 60141 20 N. Michigan Avenue, Suite 700
708/216-2006 Chicago, IL 60602
312/782-1654
Vincent A. Costanzo, Jr., M.D.
7501 South Stony Island Avenue IDPH Representative:
Chicago, IL 60649 Ron Gottrich, R.Ph
312/995-1075 Illinois Department of Public Health
525 W. Jefferson
Theodore M. Kanellakes, M.D. Springfield, IL 62761
229 N. Hammes Avenue 217/782-7532
Joliet, IL 60435
815/744-2300
Executive Officers of State Medical and
Pharmaceutical Societies
Patrick R. Staunton, M.D.
156 N. Oak Park Avenue Illinois State Medical Society
Oak Park, IL 60301 Alexander R. Lerner
708/696-5887 Executive Vice President
20 N. Michigan Avenue, Suite 700
Board of Trustees Chicago, IL 60602
Phillip D. Boren, M.D. 312/782-1654
Doctor's Clinic
S. Plum Street Illinois Pharmacists Association
Carmi, IL 62821 Mark Pilkington, R.Ph.
618/382-4193 Executive Director
223 W. Jackson, Suite 1000
Chicago, IL 60606-6908
T: 312/939-7300
F: 312/939-7220

National Pharmaceutical Council Illinois-4


Pharmaceutical Benefits 2000

Illinois Assoc. of Osteopathic Physicians &


Surgeons, Inc.
Terrill K. Haws, D.O.
Second Vice President
P.O. Box 2273
1015 La Salle
Ottawa, IL 61350
815/434-5576

State Board of Pharmacy


John Rosa
Pharmacy Coordinator
Illinois Department of Professional Regulation
Pharmacy Section
320 West Washington Street, 3rd Floor
Springfield, IL 62786
217/782-8556

Illinois Hospital and Health Systems Association


Kenneth C. Robbins
President
Center for Health Affairs
1151 East Warrenville Road
P.O. Box 3015
Naperville, IL 60566-7015
630/505-7777

5-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2000

INDIANA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC Children <21 SFO
Prescribed Drugs    
Inpatient Hospital Care    
Outpatient Hospital Care    
Laboratory & X-ray Service    
Skilled Nursing Home Services    
Physician Services    
Dental Services    
1
See Appendix E, page E-29, for a list of acronyms.

B. EXPENDITURES FOR DRUGS


1998* 1999*
Expended Recipients Expended Recipients
TOTAL $325,712,348 323,811

RECEIVING CASH ASSISTANCE, TOTAL


Aged
Blind / Disabled
AFDC-Child
AFDC-Adult
AFDC-Unemployed-Child
AFDC-Unemployed-Adult

MEDICALLY NEEDY, TOTAL


Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

POVERTY RELATED, TOTAL


Aged
Blind / Disabled
AFDC-Child
AFDC-Adult

OTHER

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1998 and 1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

National Pharmaceutical Council Indiana-1


Pharmaceutical Benefits 2000

C. ADMINISTRATION Legend Drug Reimbursement Methodology:

Office of Medicaid Policy and Planning Lower/Lowest of:


1. Federal MAC, if applicable, plus a dispensing fee.
D. PROVISIONS RELATING TO DRUGS 2. EAC plus a dispensing fee.
3. Pharmacy’s usual and customary charge to the
Benefit Design general public.

Drug Benefit Product Coverage: Products covered: Maximum Allowable Cost: State imposes Federal Upper
prescribed insulin; disposable needles and syringe Limits. Override requires “Brand Medically Necessary.”
combinations used for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Incentive Fee: None.
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs. Patient Cost Sharing: Copayment varies from $0.50 to
$3.00 for branded drugs and is $0.50 for generic drugs.
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: Indiana has a Medicaid OTC Cognitive Services: None.
drug formulary. Listed drugs are reimbursed based on
State MAC. E. USE OF MANAGED CARE

Therapeutic Category Coverage: All coverage in Approximately 330,000 total unduplicated number of
accordance with OBRA ’90 & ’93. Medicaid recipients were enrolled in MCOs in FY 2000.
Recipients receive pharmaceutical benefits through
Coverage of Injectables: Covered. managed care plans.

Vaccines: Vaccines reimbursable as part of the EPSDT F. STATE CONTACTS


service, the Children Health Insurance Program, and the
Vaccines for Children Program. State Drug Program Administrator
Marc Shirley, R.Ph.
Unit Dose: In accordance with OBRA 1990
Pharmacy Program Director
Requirements. MCFA policy only.
Office of Medicaid Policy and Planning
Room W382
Formulary/Prior Authorization
Indiana State Government Center South
402 W. Washington Street
Formulary: No formulary for legend drugs. All coverage
Indianapolis, IN 46204-2739
in accordance with OBRA ’90 & ’93. No PA for drugs.
T: 317/232-4343
F: 317/232-7382
Prior Authorization: State currently does not have a
E-mail: mshirley@fssa.state.in.us
formal prior authorization procedure.
*DO NOT CONTACT STATE DRUG PROGRAM
Prescribing or Dispensing Limitations ADMINISTRATOR WITH SURVEYS. DIRECT ALL
INDUSTRY/INDUCTRY CONTRACTOR
Prescribing Refill Limit: None. INQUIRIES IN WRITING TO:
Drug Utilization Review EDS
950 N. Meridian St, 10th Floor
PRODUR system implemented in March 1996. State Indianapolis, IN 46704
currently has a DUR Board with a quarterly review.
NO PHONE SURVEYS WILL BE ACCEPTED
Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $4.00, effective November 1989.

Ingredient Reimbursement Basis: EAC = AWP - 10%.

2-Indiana National Pharmaceutical Council


Pharmaceutical Benefits 2000

DUR Contact Medicaid Managed Care Contact


Karen Baer Sharon Steadman
DUR Board Secretary Managed Care Director
Office of Medicaid Policy & Planning Office of Medicaid Policy and Planning
Room W-382, Indiana Sate Government Center South, 402 W. Washington St
402 West Washington St. Room W382, MS07
Indianapolis, IN 46204 Indianapolis, IN 46204
T: 317/232-4391 T: 317/233-4697
F: 317/232-7382 F: 317/232-7382
E-mail: kbaer@fssa.state.in.us
Physician-Administered Drug Program Contact
Medicaid DUR Board
EDS
Physicians
950 N. Meridian Street, 10th Floor
Thomas Bright, M.D.
Indianapolis, IN 46204
Neil Irick, M.D.
Patricia Treadwell, M.D.
Administration Officials
John J. Wienert, M.D.
Kathleen D. Gifford
Pharmacists Assistant Secretary
Paula Ceh, R.Ph. Medicaid Policy & Planning
Hamid Abbaspour, R.Ph. Indiana Family & Social Services Administration
Thomas A. Smith, R.Ph. 402 W. Washington Street, Room W382
G. Thomas Wilson, R.Ph. Indianapolis, IN 46204
317/233-4455
Health Care Economist
(Vacant) Sharon Steadman
Managed Care Director
Pharmacologist 317/233-4697
Terry Lindstrom, Ph.D.
Pat Nolting, Director
Representative from Med Care Medicaid Program Operations
Kirby Davis, R.Ph. 317/232-4318

Prescription Pricing Updating Medicaid Advisory Committee


John B. DeLap
First Data Bank
2365 Chestnut Street
Columbus, IN 47201
Medicaid Drug Rebate Contacts
Marcia Finn Deborah A. Freund
Myers and Stauffer/EDS 1327 East First Street
317/488-5000 Bloomington, IN 47402

Eleanor DeArman Kinney


Claims Submission Contact
5140 Reed Road
EDS Indianapolis, IN 46254
950 N. Meridian Street, 10th Floor
Indianapolis, IN 46204 Kayla Templin West
1014 N. Arsenal Avenue
Indianapolis, IN 46201

Edward A. White, D.O.


410 North Main Street
Princeton, IN 47670-1516

National Pharmaceutical Council Indiana-3


Pharmaceutical Benefits 2000

Beverly Richards, D.N.S., R.N. Vickie Trout


Indiana St. Nurses Association Division of Mental Health
2915 North High School Road 402 W. Washington - W 353
Indianapolis, IN 46224-2969 Indianapolis, IN 46204

David Giles, M.D. David Harris


6934 Hillsdale Court 125 East 48th Street
Indianapolis, IN 46250 Indianapolis, IN 46205

L. Richard Gohman Donald Mulligan, Sr.


One American Sq. - Ste 1100 6185 Broughton
Indianapolis, IN 46204 Portage, IN 46368

Polly E. Hendricks, O.D. Barry Delks


3222 Oceanline E. Drive 21 Peregrine Court
Indianapolis, IN 46214 West Lafayette, IN 47906

James F. Jones, M.S. Lula E. Baxter


101 W. Ohio Street - Ste 610 9710 East 38th Street
Indianapolis, IN 46204 Indianapolis, IN 46236

Mike Weber R. Stanley Wilson, M.D.


Indiana Health Care Association 3 Hazelwood Drive
One N. Capital, Ste 1115 Vinciennes, IN 47591
Indianapolis, IN 46204
Paul Schneider, Ph.D.
Anna Schenk, Pres., ILPNA 6320 Latona Court
1501 W. 500 North Indianapolis, IN 46278
Marion, IN 47952
Robert S. Mandresh, D.P.M.
Paul C. Johnson, D.D.S. 3351 N. Meridian #101
8240 Naab Road Indianapolis, IN 46208
Indianapolis, IN 46260
Chip Garver
Robin Taylor, R.Ph., President 101 West Ohio, Suite 560
Healthcare Prescription Svs, Inc. Indianapolis, IN 46204
3830 E. Southport Road, Ste C
Indianapolis, IN 46237 Michael Sullivan
Ind. Assn. For Home Care, Inc.
Greg Wilson, M.D. 8888 Keystone Crossing
Developmental Pediatrics Suite 1000
702 Barnhill Dr., Room 1601 Indianapolis, IN 46202
Indianapolis, IN 46202
Louis Cantor, M.D.
Sen. Marvin Riegsecker 702 Rotary Circle
801 S. 6th Street Indianapolis, IN 46202
Goshen, IN 46526
Joe D. Hunt, Director
Rep. William Crawford Bureau of Policy Development
PO Box 18446 State Department of Health
Indianapolis, IN 46218-0446 1330 W. Michigan Street
Indianapolis, IN 46202
Rep. Jeffrey K. Espich
1250 W. Hancock Street, Box 158
Uniondale, IN 46791

4-Indiana National Pharmaceutical Council


Pharmaceutical Benefits 2000

Executive Officers of State Medical and


Pharmaceutical Societies
Indiana State Medical Association
Richard R. King
Executive Director
322 Canal Walk, Canal Level
Indianapolis, IN 46202-3252
317/261-2060

Indiana Pharmacists Association


Larry Sage
Executive Vice President
156 E. Market Street, #900
Indianapolis, IN 46204
317/634-4968

Indiana Association of Osteopathic Physicians and


Surgeons, Inc.
Michael Claphan
Executive Director
3520 Guion Road, #202
Indianapolis, IN 46222
317/926-3009

State Board of Pharmacy


Kristen Burch
Director

Indiana Health Professions Bureau


402 West Washington Street, Room 041
Indianapolis, IN 46204-2739
317/232-1140

Indiana Hospital and Health Association


Kenneth G. Stella
President
One American Square
P.O. Box 82063
Indianapolis, IN 46282

National Pharmaceutical Council Indiana-5


Pharmaceutical Benefits 2000

IOWA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE1


Type of Benefit Categorically Needy Medically Needy (MN) Other
OAA AB APTD AFDC OAA AB APTD AFDC* Children <21 SFO
Prescribed Drugs         
Inpatient Hospital Care         
Outpatient Hospital Care         
Laboratory & X-ray Service         
Skilled Nursing Home Services         
Physician Services         
Dental Services         
1
See Appendix E, page E-29, for a list of acronyms.
*Pregnant women

B. EXPENDITURES FOR DRUGS


1998 1999*
Expended Recipients Expended Recipients
TOTAL $147,115,884 215,173

RECEIVING CASH ASSISTANCE TOTAL $82,025,517 99,753


Aged $11,582,919 8,054
Blind / Disabled $57,606,338 33,570
AFDC-Child $5,286,110 32,489
AFDC-Adult $6,159,274 18,297
AFDC-Unemployed-Child $492,801 3,817
AFDC-Unemployed-Adult $898,075 3,526

MEDICALLY NEEDY, TOTAL $11,600,186 8,454


Aged $4,661,291 3,388
Blind / Disabled $5,986,116 2,540
AFDC-Child $197,038 742
AFDC-Adult $755,741 1,784

POVERTY RELATED, TOTAL $6,054,769 34,692


Aged $1,201,194 1,478
Blind / Disabled $1,355,437 1,060
AFDC-Child $2,707,203 24,765
AFDC-Adult $790,935 7,389

OTHER $46,573,607 67,074

Source: HHS State HCFA-2082 Reports, Sections A-4 and B-4.


*1999 expenditures broken down by maintenance assistance status and basis of eligibility are unavailable.

1-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2000

− Permethrin Liquid 1%
C. ADMINISTRATION
− Pseudoephedrine Hydrochloride: 30/60 mg Tablets;
30mg/5mg Liquid
State Department of Human Services, Division of Medical
− Salicylic Acid Liquid 17%
Services.
− Senokot: 326 mg/tsp Granules for children aged 20
and under; 187 mg Tablets for children aged 20 and
D. PROVISIONS RELATING TO DRUGS under
− Sodium Chloride Solution 0.9% for inhalation, with
Benefit Design metered dispensing valve 90 ml, 240 ml
− Tolnaftate 1% Cream, Solution, Powder
Drug Benefit Product Coverage: Products covered:
− Nonprescription multiple vitamin and mineral
prescribed insulin. Products covered requiring prior
products specifically formulated and recommended for
authorization: PPIs; dipyridamole; epoetin; filgrastim;
use as a dietary supplement during pregnancy and
vitamins; ergotamine derivatives; narcotic agonist-
lactation
antagonist nasal sprays; isotretinoin; oral antifungals; non-
− With prior authorization, nonprescription multiple
parenteral vasopressin derivatives; and Serotonin 5-HT1
vitamins and minerals under the conditions specified
receptor agonists. Products not covered: fertility drugs;
in subparagraph 78.1(2) “a” (3)
experimental drugs; cosmetics; disposable needles and
syringe combinations for insulin; blood glucose test strips; − Insulin
urine ketone test strips; total parenteral nutrition; and − Oral solid forms of the above-covered items shall be
interdialytic parenteral nutrition. prescribed and dispensed in a minimum quantity of
100 units per prescription or the currently available
Over-the-Counter Product Coverage: Products covered consumer package size except when dispensed via a
with restriction (selected products): allergy, asthma and unit dose system. When used for maintenance therapy,
sinus products; analgesics; cough and cold preparations; all of the above-listed items may be prescribed and
H2 antagonists; and topical products. Products not dispensed in 90-day quantities
covered: digestive products; feminine products; and
smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; antibiotics; anticoagulants;
The Iowa Department of Human Services adopted an anticonvulsants; antidepressants; antidiabetic agents;
administrative rule that permits coverage for these non- antilipemic agents; anti-psychotics; anxiolytics, sedatives,
prescription drugs: and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti-
− Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin
inflammatory agents; estrogens; hypotensive agents;
Enteric Coated: 325/650mg Tabs; 81mg Chewable;
sympathominetics (adrenergic); and thyroid agents. Prior
Aspirin Tablets Buffered, 325 mg
authorization required for: analgesics, antipyretics,
− Acetaminophen: 325/500mg Tablets; 120mg/5ml and
NSAIDs; amphetamines; antihistamine drugs; growth
160mg/5mL Elixir; 100 mg/ml Solution; 120mg
hormones; and misc. GI drugs. Therapeutic categories not
Suppositories
covered: anorectics and prescribed smoking deterrents.
− Bacitracin Ointment 500 units/gm
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,
Coverage of Injectables: Injectable medicines
Cream, Gel
reimbursable through the Prescription Drug Program
− Chlorpheniramine Maleate Tablets 4 mg when used in home health care, extended care facilities,
− Diphenhydramine Hydrochloride: 25 mg Capsules; and through physician payment when used in physicians
6.25mg/5mL and 12.5mg/5ml Liquid offices.
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml
Elixir; 75 mg/0.6 ml Drops Vaccines: Vaccines reimbursable as part of the EPSDT
− Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml service and the Vaccines for Children Program.
Elixir
− Ferrous Fumarate Tablets 300 mg, 325 mg Unit Dose: Unit dose packaging reimbursable.
− Guafenesin 100 mg/5 ml with Dextromethorphan 10
mg/5 ml liquid
− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg
− Miconazole Nitrate: Topical and Vaginal Cream 2%,
Vaginal Suppositories, 100mg
− Nicotinic Acid (Niacin) Tablets: 25/50/100/250/500
mg
− Pediatric Oral Electrolyte Solutions

National Pharmaceutical Council Iowa-2


Pharmaceutical Benefits 2000

John Deere Healthplan


Formulary/Prior Authorization
Cynthia Greene
Administrator / Government Programs
Formulary: No formulary.
Attn: Government Programs
1300 River Drive, Suite 200
Prior Authorization: State currently has a formal prior
Moline, IA 61265
authorization procedure. State appeals and a fair hearing
309/765-7637
procedure required for appeal of prior authorization
decisions and coverage of an excluded product.
Coventry Health Care of Iowa
Lou Garcia, Executive Director
Prescribing and Dispensing Limitations: 4600 Westown Parkway, Ste. 301
Des Moines, IA 50392-0445
Prescribing or Dispensing Limitations: None. 515/225-1234
Drug Utilization Review Iowa Health Solutions
Paul Carter, President
PRODUR system implemented in July 1997. State 2550 Middle Road, Ste. 405
currently has a DUR Board with a monthly review. Bettendorf, IA 52722
319/359-8999
Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $4.13 to $6.42, effective 7/1/00. F. STATE CONTACTS

Ingredient Reimbursement Basis: EAC = AWP - 10%. State Drug Program Administrator
Ronald Mahrenholz, R.Ph., M.S.
Prescription Charge Formula: Payment will be based on Pharmacist Consultant
the pharmacist's usual, customary and reasonable charge, Division of Medical Services
but payment may not exceed EAC plus a dispensing fee. Dept. of Human Services
Hoover State Office Bldg.
Maximum Allowable Cost: State imposes Federal Upper Des Moines, IA 50319
Limits on generic drugs. Override requires “Brand T: 515/281-6199
Medically Necessary.” F: 515/281-6230
E-mail: rmahren@dhs.state.ia.us
Incentive Fee: None.
Prior Authorization Contact
Patient Cost Sharing: Copayment of $1.00 branded and
generic (federal exclusions). Randy Brentnall, R.Ph.
Consultec, Inc.
Cognitive Services: Does not pay for cognitive services. P.O. Box 14422
Des Moines, IA 50306-3422
E. USE OF MANAGED CARE T: 515/327-1322
F: 515/327-0945
Iowa Medicaid recipients receive pharmaceutical benefits
through the state. DUR Contact

Managed Care Organizations Cheryl Clarke, R.Ph.


United Health Care of the Midlands, Inc. /Share DUR Coordinator
Kathy Ellithorpe Iowa Pharmacists Association
2717 North 118th Circle 8515 Douglas Ave, Suite 16
Omaha, NE 68164 Des Moines, IA 50322
402/445-5566 T: 515/270-0713
F: 515/270-2979
E-mail: cclarke@iowapharmacists.org

3-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2000

IPA Medicaid Advisory Committee


Medicaid DUR Board
Joe Cunningham
Ronnie Martin, R.Ph., D.O. 608 5th St. SW
Rick Wilkens, M.D. Waukon, IA 52172
Ilyenn Wiesley, R.Ph. 319/568-4267
Sharon Meyer, Pharm.D., M.S.
Ronald Miller, M.D. Robert Dean
Stephen Elliott, D.O., Ph.D. 2725 S. Paxton
R. Joe Mahrenholz, R.Ph., M.S. Sioux City, IA 51106
James F. Scott, R.Ph. 712/276-1307
Paul Perry, Ph.D.
Derek Duncan
Prescription Price Updating 4836 71st Street
Urbandale, IA 50322
Sherry Swanson 515/266-3174
Deputy Account Manager
Consultec, Inc. Helen Eddy
P. O. Box 14422 209 S. 27th St.
Des Moines, IA 50306-3422 West Des Moines, IA 50265
T: 515/327-0950 ext. 1107 515/267-2800
F: 515/327-0945
Hal Jackson
Medicaid Drug Rebate Contacts 218 S. 4th Ave.
Technical: Rocco Russo, 515/327-0950 ext. 1114 Winterset, IA 50273
Policy: Ron Mahrenholz, 515/281-6199 515/462-2479
Audits: Rocco Russo, 515/327-0950 ext. 1114
DUR: Cheryl Clarke, 515/270-0713 Patty Kumbera
PA: Randy Brentnall, 515/327-0950 ext. 1322 4704 80th Place
Urbandale, IA 50322
Claims Submission Contact 515/276-0679

Kristi Sheakley Beverly McMahon


Account Manager 625 Davis Ave.
Consultec, Inc. Corning, IA 50841
P. O. Box 14422 515/322-3324
Des Moines, IA 50306-3422
T: 515/327-0950 ext. 1108 Mark Richards
F: 515/327-0945 8119 Oakwood Dr.
Urbandale, IA 50322
515/278/0778
Medicaid Managed Care Contact
Dann Stevens Kenneth Hampson
MHC Program Manager PO Box 271
Medical Services- DHS Ames, IA 50010
Hoover Building, 5th Floor 515/232-7315
T: 515/281-7269
F: 515/281-6230 Alan Shepley
113 1st St. East
Mount Vernon, IA 52314
Physician-Administered Drug Program Contact 319/895-6248
Sherry Swanson
Consultec, Inc. Wally Tschopp
P. O. Box 14422 861 1st St. SE
Des Moines, IA 50306-3422 Hartley, IA 51346
T: 515/327-0950 ext. 1107 712/728-2563
F: 515/327-0945

National Pharmaceutical Council Iowa-4


Pharmaceutical Benefits 2000

John Swegle Iowa Senate


833 1st St. NW Sen. Elaine Szymoniak
Mason City, IA 50401 2116-44th Street
515/422-0587 Des Moines, IA 50310
Iowa Human Services Department Officials
Iowa State Dept. of Public Health
Jessie K. Rasmussen, Director Dr. Edward Schor
Dept. of Human Services Lucas State Office Bldg.
Hoover State Office Bldg. Des Moines, IA 50319
Des Moines, IA 50319
515/281-8621 Public Representatives
Vacant
Denis Headlee, Administrator Diana Walvoord
Division of Medical Services 503 3rd Ave S.E.
Spencer, IA 5130